Lexington House
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 16 Heyman Lane, Alexandria, Louisiana 71303
- CMS Provider Number
- 195424
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lexington House during CMS and state inspections, most recent first.
Surveyors found that staff failed to keep call lights within reach for three dependent residents with conditions such as hemiplegia, muscle weakness, gait abnormalities, and a history of falls. In each case, the call light was observed hanging off the side of the bed or lying on the floor, and the resident reported being unable to locate it. CNAs and an LPN acknowledged that call lights were supposed to be on the bed and within residents’ reach at all times, consistent with facility policy, but this was not done for these residents.
A resident with severe cognitive impairment, hemiplegia, and a left AKA reported right lower extremity pain, and imaging confirmed traumatic fractures of the tibia and fibula. The facility classified this as an injury of unknown origin but did not complete a thorough investigation as required by policy: a CNA who had provided care in the 48 hours before the injury was not interviewed or asked for a statement, and the administrator, despite having access to 72 hours of video surveillance, reviewed only the most recent 24 hours prior to discovery of the injury.
A CNA instructed a resident with moderate cognitive impairment and multiple health conditions not to use the call light because she was busy, an action confirmed by both the CNA and the DON as inappropriate and disrespectful. The resident reported this was not the first occurrence, and facility policy requires staff to treat all residents with dignity and respect.
Staff were observed preparing pureed foods without measuring portions or following prescribed recipes, instead relying on visual estimation. The dietary aide and manager both confirmed that recipes were not followed, and the dietician noted this could result in inaccurate nutritional content for residents on pureed diets. This practice had the potential to affect multiple residents receiving pureed diets.
The facility did not maintain a clean and sanitary kitchen, with unlabeled open food items, staff not wearing required hair and beard restraints, unsanitary air conditioner vents, and improper dish sanitization practices. Logs for dishwasher temperatures were also incomplete, and these failures had the potential to affect all residents receiving meals.
A resident with severe cognitive impairment and total care needs was repeatedly observed in bed with the call light on the floor and out of reach, despite facility policy and the care plan requiring it to be accessible. Staff confirmed the call light was not within reach as required.
Two residents were not given the required SNF ABN (CMS-10055) before their Medicare Part A services were discontinued, even though benefit days remained. In both cases, the Accounts Manager stated she was unaware of the need to provide this notice prior to ending skilled services, and both residents continued to reside in the facility after skilled services ended.
Two residents were affected by the facility's failure to follow and develop person-centered care plans. One resident, with moderate cognitive impairment and multiple chronic conditions, was found keeping cigarettes and a lighter in her wheelchair pouch despite a care plan and policy requiring these items to be stored at the nurses' station. Another resident with severe cognitive impairment and a history of eating non-food items was not timely care planned for this behavior, even after multiple incidents of chewing or ingesting non-food items were documented. Staff confirmed these lapses during interviews and record reviews.
The facility did not ensure physician-ordered wound care was provided and documented for three residents with complex medical needs, including pressure ulcers, diabetic ulcers, and skin tears. Wound care was missed or undocumented on multiple occasions, and staff confirmed that treatments were not completed as required.
The facility did not ensure accurate documentation and proper witnessing procedures for controlled medication administration and wasting. An LPN failed to document the administration of a narcotic tablet at the time of administration for a resident, and in a separate case, two narcotic tablets wasted by a nurse lacked the required witness signature. Facility leadership confirmed that staff were aware of these documentation and witnessing requirements.
A resident with multiple medical conditions, including Alzheimer's and a history of UTIs, was observed on several occasions without a water pitcher or fluids at the bedside, despite facility policy and care plan requirements for regular fluid provision. Staff confirmed the resident had no fluid restrictions and should have had fluids available, but documentation showed inconsistent fluid offers.
A resident with a history of UTIs did not receive timely and appropriate treatment due to a breakdown in the facility's process for handling lab results. Despite a culture and sensitivity test indicating resistance to the initially prescribed antibiotic, the resident continued to receive inappropriate treatment until much later, when the correct antibiotic was finally administered.
Failure to Keep Call Lights Within Reach of Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were accessible to multiple residents, contrary to the facility’s own call light policy requiring staff to place the call light within the resident’s reach before leaving the room. For Resident #2, who had hemiplegia, generalized muscle weakness, repeated falls, and was dependent for toileting, hygiene, bathing, dressing, rolling, and transfers, surveyors observed the call light hanging off the left side of the bed, dangling below the bottom of the mattress. Resident #2 stated she was unable to locate the call light. When accompanied by S4LPN, it was confirmed that the call light was not within reach but should have been accessible to the resident at all times. For Resident #3, who had hemiplegia, paroxysmal atrial fibrillation, muscle weakness, syncope and collapse, a history of falling, and severely impaired cognition with a BIMS score of 3, surveyors observed the call light hanging off the left side of the bed near the floor. Resident #3 reported being unable to locate the call light, and S11CNA confirmed that the call light was not within reach and should have been. For Resident R4, who had abnormalities of gait and mobility, generalized muscle weakness, age-related physical debility, and repeated falls, surveyors observed the resident lying in bed with the call light on the floor to the left of the bed. S6CNA confirmed that this call light also was not within reach but should have been. Additional interviews with S10LPN and S3QI confirmed that facility practice and expectations were for call lights to be on the bed, within reach of residents, and in their hand when possible, reinforcing that the observed situations represented failures to follow established procedures.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident had diagnoses including hemiplegia, hemiparesis, dementia, and a left above-knee amputation, and was dependent for hygiene, bathing, dressing, and position changes. A Significant Change MDS showed a BIMS score of 3, indicating severely impaired cognition. On a specified date, the resident complained of pain to the right lower extremity, and x‑rays of the right knee, tibia, and fibula demonstrated traumatic fractures of the proximal tibial and fibular diaphyses and tibial shaft. The facility completed a Critical Incident Report and substantiated an injury of unknown origin based on its policy criteria that the source of the injury was not observed, could not be explained by the resident, and was suspicious due to the extent and location of the injury. Despite policy requirements that the administrator thoroughly investigate all alleged violations and injuries of unknown origin, the investigation was incomplete. Nursing staff who rendered care during the 48 hours prior to discovery of the injury were to provide statements, but a CNA who provided care to the resident from 3:00 p.m. to 11:00 p.m. on the two days before the injury was identified was not interviewed or asked for a statement, even though she confirmed she had provided care during that period. Additionally, the administrator had access to 72 hours of facility video surveillance footage prior to discovery of the injury but reviewed only the previous 24 hours and acknowledged not reviewing the full 72-hour period prior to the injury, despite stating she should have done so.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
Facility staff failed to treat a resident with respect and dignity, as required by facility policy and federal regulations. During an observation, a CNA told a resident not to use the call light anymore because she was busy. The CNA later confirmed to the surveyor that she made this statement and acknowledged it was rude. The resident, who has moderate cognitive impairment and multiple medical conditions including congestive heart failure, diabetes, and dementia, reported that this was not the first time the CNA had told her not to use the call light. At the time of the incident, the resident was observed sitting in her wheelchair with her head down and expressed that she did not want to be told not to use her call light. The Director of Nursing confirmed that it was not the expectation for any staff member to instruct a resident not to use the call light, regardless of how busy they were. The facility's policy on dignity and respect requires staff to display respect when speaking with and caring for residents, and to promote the rights of residents to a dignified existence and self-determination. The actions of the CNA were inconsistent with these requirements and resulted in a failure to ensure the resident was treated with respect and dignity.
Failure to Follow Pureed Diet Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed during meal preparation, as observed during a lunch service. A dietary aide was seen preparing pureed foods without measuring portions or adhering to the prescribed recipes, instead relying on visual estimation based on the pan size. The dietary aide confirmed that recipes and measurements were not used when preparing pureed foods. The dietary manager also confirmed that the aide did not follow the required recipes and acknowledged this was not the first occurrence, referencing prior disciplinary action. Additionally, the facility dietician confirmed that failure to follow pureed recipes could result in inaccurate nutritional content for residents receiving pureed diets. This practice had the potential to affect twelve residents who were on pureed diets.
Failure to Maintain Sanitary Kitchen and Adhere to Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not adhere to professional standards for food storage, preparation, and service. Observations revealed that food items in the pantry, such as an open bag of penne pasta, were not labeled with an open date as required. Staff were observed not wearing appropriate hair restraints, including beard restraints, while preparing food, and it was confirmed that beard restraints were unavailable at the time. Additionally, the kitchen's air conditioner vents were found to be unsanitary, covered in a black substance, and there was uncertainty regarding the last time they had been cleaned. Further deficiencies were identified in the dish sanitization process. A dietary aide was observed failing to properly sanitize dishes using the 3-compartment sink, with the sanitization strip being non-reactive on two attempts and the sanitization hose placed in the wrong compartment. The chemical sanitizer was not mixed to the proper concentration, and there was no evidence that water temperature or sanitizer levels were checked or recorded as required. Review of dishwasher temperature logs also revealed missing entries for multiple dates. These failures had the potential to affect all 115 residents who received meals from the kitchen.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's, dementia, and limited mobility, was not provided reasonable accommodation for their needs. The facility's policy and the resident's care plan both required that the call light be placed within the resident's reach to allow communication with staff. However, during multiple observations over two days, the call light was found on the floor next to the resident's bed, out of the resident's reach, while the resident was lying in bed and unable to access it. The resident was non-interviewable and required total care and extensive assistance for bed mobility. Staff confirmed during the survey that the call light was not accessible and acknowledged that it should have been within reach, as per facility policy and the resident's care plan. The repeated failure to ensure the call light was accessible constituted a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Provide Required SNF ABN Prior to Discontinuation of Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, Form CMS-10055) to residents or their responsible parties prior to discontinuing Medicare Part A services, as observed in the cases of two residents. One resident was discharged from Physical and Occupational Therapy due to non-compliance or refusal to participate, despite having Medicare benefit days remaining. The Accounts Manager confirmed that the SNF ABN was not provided because she was unaware of the form or the requirement to send it before discontinuing skilled services. Similarly, another resident was discharged from Medicare Part A services when benefit days were still available, due to cognitive inability to participate in therapy. The Accounts Manager again confirmed that the SNF ABN was not sent to the resident or their responsible party, citing lack of awareness of the form and its required use prior to discharge from skilled services. Both residents remained in the facility after skilled services were discontinued.
Failure to Implement and Develop Person-Centered Care Plans for Smoking Safety and Pica Behaviors
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to smoking safety and management of pica behaviors. For one resident with chronic respiratory failure, COPD, diabetes, and moderate cognitive impairment, the care plan specified that cigarettes and lighters should be kept at the nurses' station and only provided upon request in designated smoking areas. However, observations and interviews revealed that the resident regularly kept a pack of cigarettes and a lighter in her wheelchair pouch, contrary to the care plan and facility policy. Staff confirmed that smoking supplies were not being stored as required. Another resident with severe cognitive impairment, dementia, and a history of eating non-food items was not timely care planned for this behavior. Progress notes documented multiple incidents where the resident chewed or ingested non-food items such as straws, plastics, paper, and cloth. During an observation, the resident was found chewing on string-like material and holding a bib with holes, with staff needing to remove pieces of cloth and food from her mouth. Despite these documented behaviors, the care plan did not initially address the risk of eating non-food items, and staff confirmed the absence of a relevant care plan focus during the review period. These deficiencies were identified through record review, staff and resident interviews, and direct observation, demonstrating a lack of adherence to established care plans and failure to timely address known behavioral risks for the affected residents.
Failure to Provide Wound Care as Ordered for Multiple Residents
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that physician's orders for wound care were implemented as prescribed for three residents. For one resident with chronic respiratory failure, dysphagia, cognitive deficits, and a Stage 3 sacral pressure ulcer, wound care orders were not followed as documented in the Treatment Administration Record (TAR). The wound care was missed on multiple days in April and May, with the Director of Nursing (DON) confirming that documentation was lacking and care was not completed as ordered. Another resident with diabetes, a recent amputation, peripheral vascular disease, and a diabetic foot ulcer also did not receive wound care as ordered. The electronic TAR (eTAR) showed that wound care for the diabetic ulcer and for moisture-associated skin damage (MASD) to the buttocks was not completed on several days in April and May. The DON acknowledged that wound care was not documented or completed as required by the physician's orders. A third resident with chronic respiratory failure, COPD, Parkinson's disease, and dementia had a skin tear to the right eyebrow. The care plan required daily wound care, but there was no evidence of an order to complete this care in the eTAR, and observations revealed the dressing was undated and the wound had dried blood. An LPN confirmed that the treatment should have been performed daily and the dressing should have been dated, but this was not done.
Failure to Accurately Document and Witness Controlled Medication Administration and Wasting
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administration of medications for its residents. Specifically, during a controlled medication reconciliation, it was found that a nurse administered a Clonazepam tablet to a resident but did not document the administration in the clinical record at the time it occurred. The nurse confirmed the omission, and facility leadership acknowledged that all floor nurses were aware of the requirement to document narcotic administration promptly in the clinical record. Additionally, the facility did not follow proper procedures for wasting or destroying narcotic medications. In one instance, two Oxycodone/Acetaminophen tablets were documented as wasted after being dropped, but there was no evidence of a required witness or second signature for either event. The nurse involved confirmed the lack of a witness signature, and the DON verified that all nurses were expected to have a witness and document accordingly when wasting narcotics. These failures were observed on two separate medication carts and involved two different residents.
Failure to Provide Sufficient Fluids for Hydration
Penalty
Summary
The facility failed to provide sufficient fluids to maintain adequate hydration for one resident, as required by facility policy and the resident's care plan. Multiple observations over several days revealed that the resident did not have a water pitcher or any other fluid for hydration at the bedside, despite being awake and alert in the room. The facility's policy mandates that a water pitcher with water and ice be placed at the bedside of all residents unless contraindicated, and that nursing assistants offer fluids every two hours unless restricted. Review of the resident's medical record showed no fluid restrictions, and both the CNA and LPN confirmed that the resident should have had a water pitcher available. The resident in question had a history of Alzheimer's, mild protein-calorie malnutrition, chronic ulcer, peripheral vascular disease, anxiety disorder, dysphagia, osteoarthritis, and a history of urinary tract infections. The care plan included interventions to encourage fluid intake, especially while on antibiotic therapy for a UTI, which required a minimum fluid intake per facility guidelines. Documentation of fluid offers was inconsistent and did not meet the every-two-hour standard. Staff interviews confirmed the absence of a water pitcher and acknowledged that the resident should have had one at the bedside.
Delayed Appropriate Treatment for UTI
Penalty
Summary
The facility failed to provide timely and appropriate treatment for a resident with a urinary tract infection (UTI). The resident, who had a history of UTIs and other medical conditions such as unspecified dementia and overactive bladder, was initially prescribed Bactrim DS after a urinalysis indicated elevated leukocytes and bacteria. However, a subsequent culture and sensitivity test revealed that the pathogen, Escherichia Coli, was resistant to Bactrim DS and other antibiotics, and was susceptible only to Ertapenem. Despite this, the resident continued to receive inappropriate antibiotics until the correct treatment was administered much later. The delay in appropriate treatment was due to a failure in the facility's process for handling lab results. Although the culture and sensitivity results were available and stamped by the facility shortly after being reported, they were not acted upon until much later. Interviews with facility staff revealed that lab results are faxed to the facility and can be accessed via computer, but there was a breakdown in communication and follow-up, leading to the resident not receiving the correct antibiotic in a timely manner.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
