Legacy Nursing And Rehabilitation Of Tallulah
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallulah, Louisiana.
- Location
- 32 Crothers Drive, Tallulah, Louisiana 71282
- CMS Provider Number
- 195443
- Inspections on file
- 25
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Tallulah during CMS and state inspections, most recent first.
The facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by its abuse reporting policy and state law. A cognitively impaired resident with multiple diagnoses, including dementia and a history of repeated falls, was found with bruising and swelling to the lower leg and later diagnosed by x-ray with acute fractures of the tibia and fibula. The resident could not explain the cause of the injury, and the facility’s investigation did not identify a cause, meeting the policy’s definition of an injury of unknown origin. Despite this, the Administrator, who was responsible for such notifications, did not report the incident to the State Survey Agency.
A resident with moderate cognitive impairment and multiple diagnoses underwent an x-ray of the right shoulder/arm, which was reviewed and signed by an LPN. However, there was no documented evidence that the responsible party was notified of the x-ray results in a timely manner, as confirmed by the DON.
A facility failed to assess the effectiveness and necessity of a safety device for a resident with cognitive impairment and multiple diagnoses. The resident was observed on a mattress with raised edges, but the safety device assessment did not include this intervention. Interviews with the DON and an LPN confirmed the omission.
A facility failed to provide adequate activities for a resident with blindness, who reported not being informed of upcoming activities and expressed dissatisfaction with the activities provided. Despite having a monthly activity calendar and attending some events, the resident rated their satisfaction as a 2 out of 10. The Activity Director confirmed the resident was not individually informed of activities.
The facility failed to follow proper procedures for bed rail use for four residents, lacking physician's orders, informed consent, and risk assessments. Residents with cognitive and physical impairments were observed with bed rails installed without necessary documentation, confirmed by the DON.
A facility failed to monitor a resident's medication regimen for bleeding while on anticoagulant therapy. The resident, with a history of cerebral and heart conditions, was prescribed Eliquis and Aspirin. Despite a care plan indicating a risk for bleeding and the need for monitoring, there was no documentation of such monitoring. Interviews with the DON and an LPN confirmed the absence of documentation.
The facility was found to have several food safety and storage deficiencies, including storing clean pots on a shelf with old food particles, a buildup of an unknown substance in the ice machine, improperly sealed food items in the freezer, and bottled water stored directly on the floor. These issues were confirmed by the Dietary Manager and reported to the administrator, affecting the 84 residents receiving meal trays.
The facility failed to maintain a sanitary environment in the kitchen, as personal belongings were improperly stored near food preparation areas, risking cross-contamination. Observations revealed a purse and jacket in contact with food items, and additional personal items in a storage room. The Dietary Manager confirmed these practices were against protocol, affecting meal service for 84 residents.
The facility failed to maintain safe mechanical equipment in the kitchen, with metal shavings on the can opener and grease buildup in the deep fryer. The Dietary Manager confirmed these conditions, which could affect the 84 residents receiving meal trays. The Administrator was notified of these findings.
A resident with a wedge compression fracture of the T11-T12 vertebra was unable to activate his call light due to physical disabilities, as he could not move his left arm or right fingers. This deficiency was confirmed during an interview and a room visit by the DON and a surveyor.
A resident with severe cognitive impairment and high elopement risk left the facility unnoticed after a sitter mistakenly opened an emergency exit door. The resident was found outside by an LPN and returned safely without injuries. The facility failed to report the incident to the State Survey Agency as required by policy.
A resident with dementia and high elopement risk exited a facility unnoticed due to a sitter's mistake and lack of an alert system on an exit door. The resident, wearing a wander guard, was mistaken for a visitor and allowed to leave. An LPN quickly retrieved the resident with a neighbor's help, and the resident returned unharmed. The facility's staff confirmed the deficiency, noting the absence of a code alert system on the exit door.
Two residents in the facility received medications contrary to physician orders, with nurses failing to adhere to prescribed blood pressure and insulin parameters. One resident with diabetes and hypertension was given Lisinopril and insulin without following the specified hold parameters, while another resident received Metoprolol Tartrate despite vital signs indicating it should be held. These deficiencies were confirmed through MAR reviews and staff interviews.
A resident with multiple health issues, including diabetes and blindness, did not receive adequate personal hygiene care. Observations revealed a buildup of crust and moisture between the toes, an odor from the left foot, and untrimmed nasal hairs. A CNA and LPN confirmed these findings, and the DON acknowledged the need for better hygiene practices.
Failure to Report Injury of Unknown Origin with Fracture to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin with serious bodily injury to the State Survey Agency as required by state law and the facility’s own Abuse Reporting and Investigation Policy and Procedure. The policy states that all reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source must be promptly reported to local, state, and federal agencies and thoroughly investigated, and that suspicious injuries of unknown origin, including fractures in cognitively impaired residents when not witnessed, must be reported. The facility’s policy further defines injuries of unknown origin as those not observed by any person, not explainable by the resident, and suspicious due to the extent or location of the injury. Record review showed that a resident with diagnoses including COPD, adult failure to thrive, repeated falls, generalized anxiety disorder, dementia with agitation, and delirium had severe cognitive impairment, with a BIMS score of 7, and required one-person assistance for standing and transfers. An incident report documented that this resident was found with bruising and swelling to the lower left leg in the evening, and an x-ray obtained the next day revealed acute mid and distal fractures of the tibia and fibula. The DON reported that the resident was unable to state the cause of the injury due to dementia and that the facility’s investigation could not determine a cause for the fracture, meeting the criteria for an injury of unknown origin with serious bodily injury. The Administrator, who was responsible for notifying the State Survey Agency, confirmed that the facility did not report this injury as required by the facility’s policy and state reporting requirements.
Failure to Notify Responsible Party of X-ray Results
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident's x-ray results. The resident, who had diagnoses including Alzheimer's disease, psychotic disturbance, mood disturbance, anxiety, and a history of musculoskeletal conditions, was readmitted to the facility and required assistance with activities of daily living. The resident had moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11. On a specific date, the resident was observed resting in bed with a faint pinkish area on her right forearm. A review of the medical record showed that a nurse practitioner ordered an x-ray of the resident's right shoulder/arm, and the x-ray was performed and interpreted on the same day. The LPN signed and dated the report, but there was no documented evidence that the resident's responsible party was notified of the x-ray results. This lack of timely notification was confirmed by the Director of Nursing during an interview.
Failure to Assess Safety Device for a Resident
Penalty
Summary
The facility failed to accurately assess the effectiveness and necessity of safety devices for a resident. The facility's policy on safety and supervision requires documenting interventions and evaluating their effectiveness. However, the medical records for a resident with multiple diagnoses, including muscle weakness, dystonia, mood disorder, altered mental status, and schizophrenia, did not include an assessment of the raised edge mattress being used as a safety device. Observations on two consecutive days confirmed that the resident was lying on a mattress with raised edges, but the safety device assessment did not account for this. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the omission in the assessment.
Failure to Provide Adequate Activities for Blind Resident
Penalty
Summary
The facility failed to provide an ongoing program to support a resident with blindness in their choice of activities. The resident, who had a diagnosis of blindness in both eyes, reported not receiving any activities and not being informed of when activities were going to take place. Despite being provided with a monthly activity calendar and attending some social events, the resident expressed dissatisfaction with the activities provided, rating his satisfaction level as a 2 out of 10. The Activity Director confirmed that the resident was not individually informed of upcoming activities.
Failure to Follow Bed Rail Protocols
Penalty
Summary
The facility failed to ensure proper procedures were followed for the use of bed rails for four residents. Specifically, the facility did not obtain a physician's order, informed consent from the residents or their representatives, or conduct an assessment for the risk of entrapment prior to the installation of bed rails. This deficiency was observed in residents with varying degrees of cognitive and physical impairments, including Parkinson's disease, Alzheimer's disease, and cerebrovascular conditions. Resident #30, who had intact cognition, was observed with loose bed rails, and there was no documentation of a physician's order, informed consent, or risk assessment. Similarly, Resident #23, with severe cognitive impairment, was found with bed rails raised without the necessary documentation or assessments. Resident #34, also severely impaired, and Resident #60, with moderate cognitive impairment, were both observed with bed rails installed without the required procedural steps being documented. The Director of Nursing confirmed the lack of documentation and procedural adherence for all four residents. The facility's policy on restraint devices requires an assessment of the resident's need, informed consent, and a physician's order, none of which were documented for these residents. This oversight indicates a systemic failure to comply with established protocols for bed rail use, potentially compromising resident safety.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring for bleeding in a resident receiving anticoagulant therapy. The medical records for the resident, who had a history of cerebral infarction, transient cerebral ischemic attack, atherosclerotic heart disease, old myocardial infarction, long-term use of anticoagulants, and chronic atrial fibrillation, showed an order for Eliquis and Aspirin. The care plan indicated a risk for bleeding due to anticoagulant therapy, with interventions to monitor for signs and symptoms of bleeding and notify the physician if any were observed. However, there was no documented evidence of monitoring for bleeding in the resident's medical record. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the lack of documentation for monitoring bleeding or bruising when administering the anticoagulants.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Clean pots and pans were stored on a shelf that had old food particles, indicating improper cleaning and storage practices. Additionally, the ice machine was found to have a significant buildup of an unknown black substance on the inside lid and dust accumulation on the filters, both of which were confirmed by the Dietary Manager as needing cleaning. These conditions suggest a lack of regular maintenance and sanitation in the kitchen area. Further deficiencies were noted in the storage of food items and bottled water. In the walk-in freezer, boxes of beef patties and Churro Bites were left open and exposed to air, which the Dietary Manager acknowledged as improper sealing. Moreover, flats of bottled water were stored directly on the floor in the storage room, contrary to standard storage practices. These findings were reported to the facility's administrator, highlighting the need for improved food safety and storage protocols to ensure the well-being of the 84 residents receiving meal trays from the kitchen.
Sanitation Breach in Kitchen Due to Improper Storage of Personal Items
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, which is crucial for preventing the development and transmission of communicable diseases and infections. During an observation on February 24, 2025, a purse was found on a top shelf next to food preparation items, and a jacket was in direct contact with exposed parchment paper. Additionally, a storage room in the back of the kitchen contained personal belongings, including jackets and a purse, hanging next to a cart with several cans of soup. These observations indicate a lack of adherence to proper storage protocols for personal items in food preparation and storage areas. S9Dietary, who was present during the observations, confirmed that the purse belonged to her but was unaware of the jacket's owner. S8Dietary Manager acknowledged that kitchen staff were not supposed to store personal belongings in the kitchen and storage room due to the risk of cross-contamination. The Diet Type Report indicated that 84 residents received meal trays from the kitchen, highlighting the potential impact of these unsanitary practices. The facility's administrator was informed of these findings on February 26, 2025.
Unsafe Mechanical Equipment in Kitchen
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, as evidenced by a buildup of metal shavings on the can opener and a grease buildup inside the deep fryer. During an observation of the kitchen, it was noted that the commercial can opener had a significant accumulation of metal shavings beneath the blade. Additionally, the large gas fryer was observed to have a buildup of grease on its internal components. These observations were confirmed by the Dietary Manager, who was present at the time. The facility's Diet Type Report indicated that a total of 84 residents received meal trays from the kitchen, potentially exposing them to the risks associated with the equipment's condition. The Administrator was informed of these findings two days later.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident who was unable to activate his call light due to physical disabilities. The resident, who was admitted with a diagnosis of wedge compression fracture of the T11-T12 vertebra, demonstrated his inability to move his left arm and right fingers, which prevented him from pressing the call light button. During an interview, the resident confirmed his inability to activate the call light, and this was further verified by the Director of Nursing during a room visit with the surveyor.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident with severe cognitive impairment and a high risk for elopement. The resident, diagnosed with unspecified dementia and wandering behavior, was able to leave the facility without staff awareness. The incident occurred when a sitter, mistaking the resident for a visitor, opened an emergency exit door, allowing the resident to exit the building. The resident was later found walking outside the facility by an LPN, who, with the help of a neighbor, returned the resident to the facility without any observed injuries. The facility's policy required incidents of elopement to be reported to the State Survey Agency within 24 hours, but this was not done. The administrator confirmed that the incident was not reported in the Statewide Incident Management System (SIMS). The resident was assessed as high risk for elopement, and the incident highlighted a lapse in supervision and communication among staff, as the resident was able to leave the facility unnoticed until informed by the sitter.
Resident Elopement Due to Inadequate Supervision and Lack of Alert System
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, diagnosed with unspecified dementia and behavioral disturbances, was assessed as having severe cognitive impairment and was noted to be independent with transfers. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility without staff awareness due to a lapse in supervision. The incident occurred when a private sitter for another resident mistakenly allowed the resident to exit through an emergency door, believing the resident to be a visitor. The resident was observed walking outside the facility by a Licensed Practical Nurse (LPN) who was informed by the sitter. The LPN immediately pursued the resident and, with the assistance of a neighbor, returned the resident to the facility without injury. The resident was found to be in stable condition with no agitation or distress. Interviews with facility staff revealed that the exit door used by the resident did not have a code alert bracelet system to notify staff of the resident's proximity. This lack of an alert system contributed to the staff's unawareness of the resident's exit. The Director of Nursing and the Administrator confirmed the deficiency, acknowledging that the resident was able to elope without staff knowledge until the incident was reported by the sitter.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, specifically for two residents who were reviewed for unnecessary medications. For one resident, the facility did not adhere to the prescribed insulin sliding scale and blood pressure parameters. The resident had a history of type 2 diabetes mellitus, hypertension, and other significant health conditions. Despite having clear physician orders to hold Lisinopril if the diastolic blood pressure was below 75 and to hold insulin if the blood sugar was below 150, the nurses administered these medications multiple times without following the parameters. This oversight was confirmed through interviews with the LPNs and the Director of Nursing. Another resident, who also had a history of hypertension and other health issues, was affected by the facility's failure to follow prescribed blood pressure parameters. The resident's physician orders specified holding Metoprolol Tartrate if the pulse was below 60 or systolic blood pressure was below 110. However, the medication was administered several times despite the resident's vital signs being outside the specified parameters. This was confirmed through a review of the Medication Administration Records and interviews with the nursing staff. The surveyor's findings highlighted a pattern of non-compliance with medication administration protocols, as evidenced by the repeated failure to adhere to physician orders for both residents. The Director of Nursing acknowledged these deficiencies during the surveyor's review, and the facility's administrator was informed of the findings. The report underscores the importance of following physician orders to ensure the safety and well-being of residents in the facility.
Deficiency in Resident Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus with diabetic retinopathy, hemiplegia, hemiparesis, and blindness, required extensive assistance with personal hygiene. During an observation, it was noted that the resident had a thick buildup of black crust between the toes, areas of moisture with a sticky white coating, and an odor emanating from the left foot. Additionally, the resident had long, untrimmed nasal hairs. These findings were confirmed by a CNA and later by an LPN, who acknowledged the need for further attention to the resident's hygiene. The Director of Nursing was informed of the hygiene issues, including the crusty buildup and odor between the resident's toes and the untrimmed nasal hairs. The DON confirmed that the resident's feet should have been cleaned during baths and nasal hairs trimmed. The facility's failure to ensure the resident's personal hygiene needs were met was documented, highlighting a deficiency in the care provided to the resident.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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