Luling Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Luling, Louisiana.
- Location
- 1125 Paul Maillard Rd, Luling, Louisiana 70070
- CMS Provider Number
- 195645
- Inspections on file
- 6
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 15 (2 serious)
Citation history
Health deficiencies cited at Luling Living Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a clearly documented full code status was found unresponsive, pulseless, and not breathing. Staff policy and American Heart Association guidelines required immediate, continuous CPR until advanced medical providers arrived, but video review and interviews showed that no CPR equipment was brought to the room and no continuous CPR was provided. An LPN assumed the resident was DNR because hospice services were in place and did not verify code status, while another LPN acknowledged not initiating CPR until instructed by the DON. The hospice nurse arrived to find the resident covered with no life-saving measures in progress, despite existing orders for full code, and the facility could not produce evidence that the resident’s code status was promptly verified or that CPR was continuously performed.
The facility failed to ensure that a resident with a physician’s order for full code status received timely and continuous CPR when found unresponsive, as nursing staff did not accurately verify the resident’s code status and did not maintain resuscitation efforts until EMS arrival, and facility leadership did not initially recognize or investigate this as deficient practice or provide staff re-education on CPR and code status verification. In addition, when no Treatment Nurse was on duty, multiple residents with Stage III and Stage IV pressure ulcers did not receive ordered wound care because LPNs were not clearly informed they were responsible for performing wound treatments on their assigned residents, despite the expectation by the DON and RN Supervisor that floor nurses would assume this role.
The facility failed to provide physician-ordered daily wound care for three residents with Stage II–IV pressure ulcers to the sacrum and heel. Each resident had specific orders for daily cleansing, application of Santyl and/or Collagenase, use of calcium alginate, and coverage with silicone foam border dressings, with changes every day and as needed. Treatment records showed that ordered wound care was not completed on multiple consecutive days, and dressings observed in place were dated several days earlier. The treatment nurse, LPNs assigned on those days, the DON, and a contracted wound care NP all acknowledged that the daily pressure ulcer treatments were not performed as ordered.
The facility failed to maintain complete and accurate clinical records for multiple residents, including missing documentation on MARs for ordered medications such as antidepressants, anticoagulants, antibiotics, and sleep aids, and missing entries on TARs for ordered wound care, low air loss mattress use, and pain assessments. ADL records also lacked required charting of bed mobility, toileting, transfers, and other self-care assistance for several residents whose care plans and assessments showed they required staff help. The DON, CNA Supervisor, and a contracted wound care nurse all confirmed that these medications, treatments, and ADL services should have been documented, leaving the facility unable to verify that physician-ordered care was provided as required.
Missed Medication Administrations: A resident had multiple ordered medications omitted without documented reasons, including doses of Simethicone, Gabapentin, Meloxicam, Sertraline, and Pataday eye drops. An LPN believed one medication was out of stock but did not verify availability, while the DON and RN confirmed the medications were available and should have been given as ordered.
A resident with a broken lower molar and dental pain did not receive the planned follow-up dental care after a contracted dental cleaning. The dentist requested a triage form so the resident could be seen, but Social Services did not complete it in time for the scheduled dental visit, and the DON stated it should have been sent earlier.
A resident with an enteral tube had an active order for Diabetisource at 45 mL/hr with a 200 mL water flush every hour, but observations showed the pump was set to give a 150 mL water flush every 4 hours instead. An LPN confirmed the pump settings did not match the physician's order, and the DON acknowledged the ordered flush was not being administered as prescribed.
Failure to Coordinate Hospice Documentation: A resident admitted for hospice services did not have the required hospice binder at the facility, and staff could not provide the admission orders and hospice documentation expected to coordinate care. The DON, an LPN, the hospice agency's records representative, and the Administrator all confirmed the binder was missing and should have been available.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and indicated a failure to meet required standards for resident care.
Two residents did not have their medical records accurately documented, as LPNs recorded completion of suprapubic catheter care and use of a pressure relieving cushion without actually performing or verifying these tasks. The DON confirmed the inaccuracies, and the Administrator did not dispute the findings.
The facility did not ensure that direct care staff received effective communication training, as required. Personnel records for several CNAs showed no evidence of this training, and both the CNA Supervisor and DON confirmed that such training was not part of orientation or in-service programs.
The facility did not provide required QAPI training to several CNAs, as confirmed by personnel record reviews and staff interviews. The CNA Supervisor acknowledged that QAPI training was not part of orientation or in-service education, and the DON confirmed the deficiency.
The facility did not ensure its facility-wide assessment included input from direct care staff (RN, LPN, CNA), a resident, and resident representatives, nor did it document the current resident census. The administrator confirmed these omissions during the survey.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
For three consecutive days, the facility did not post complete nurse staffing information at the start of each shift, omitting both the daily census and the actual hours worked by RNs, LPNs, and CNAs. This deficiency was confirmed by the DON and the Administrator.
Failure to Provide CPR According to Full Code Status and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, in accordance with a resident’s documented full code status and physician orders. The facility’s CPR policy required staff to provide basic life support prior to the arrival of emergency personnel, consistent with the resident’s physician orders and advance directives. The American Heart Association Basic Life Support Algorithm referenced in the report emphasized that high-quality CPR is the most critical part of basic life support and should continue until advanced medical providers arrive or the patient shows signs of life. For this resident, multiple documents, including a Louisiana Physician Orders for Scope of Treatment form, monthly physician orders, hospice certification and plan of care, and the comprehensive care plan, all indicated a full code status, requiring CPR if the resident was unresponsive, pulseless, and not breathing. On the day of the incident, the resident, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and chronic obstructive pulmonary disease, was found unresponsive and not breathing. Surveillance footage showed that a CNA exited the resident’s room and quickly summoned the CNA supervisor, who then returned to the room and called for additional staff. Two LPNs entered the room shortly thereafter, but video review from the time the incident began until well after showed that no cardiopulmonary emergency equipment, such as a backboard, Ambu bag, or crash cart, was brought into the room. Documentation in a health status note by one of the LPNs stated that she was summoned to the room, found the resident unresponsive and not breathing, and that she attempted CPR but was unsuccessful, with the time of death later documented as pronounced by the hospice nurse. Interviews and video review, however, did not corroborate that CPR was initiated or continued as required. One LPN reported that when she assessed the resident, he had no pulse, was still warm, and showed no signs of prolonged death, but she did not discuss or verify the resident’s code status and assumed the resident was DNR because he was on hospice. She stated she was not aware the resident was full code and had not observed anyone performing CPR. The DON reported that the other LPN had initially believed the resident was DNR and admitted she had not yet implemented CPR; the DON then instructed her to return to the room and start CPR. The hospice nurse stated she was notified that the resident had expired and, upon arrival, found the resident in bed with a sheet over his head and no life-saving measures in progress. She was told that CPR had been started and stopped, but she did not instruct staff to stop CPR and expected it to continue until EMS or a physician directed otherwise. The facility was unable to provide evidence that any licensed nursing staff immediately verified the resident’s code status or ensured continuous CPR from the time the resident was found without a pulse and not breathing until the official time of death, resulting in an Immediate Jeopardy determination.
Removal Plan
- S5LPN was in-serviced on checking Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR.
- All active residents' EMARs were reviewed to ensure code status was posted.
- All nurses for each shift were in-serviced for checking code status in the EMAR and proper procedures for CPR.
- Implemented a policy to train all nurses on checking code status in the EMAR and proper procedures for CPR prior to working on the floor.
- All new hire nurses will be trained on checking code status and proper procedures for CPR prior to working on the floor.
- Removed the code status binder and red dot stickers; they are no longer in use.
- Required that a resident's code status must be checked in the EMAR.
- The DON will monitor weekly to ensure proper training is provided to all nurses and completed prior to working on the floor.
- The DON will audit training documents prior to scheduling nurses to the floor on a weekly basis and before all new hires.
- The DON will not schedule any nurse who has not completed the required training.
Failure to Ensure CPR per Code Status and Wound Care Coverage in Absence of Treatment Nurse
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical well-being, specifically in relation to CPR and code status verification. One resident with a physician’s order for full code status was found unresponsive, pulseless, and not breathing. Licensed nursing staff did not accurately determine this resident’s code status and failed to initiate and continuously provide CPR in accordance with the physician’s full code order until EMS arrived. When the hospice nurse arrived, no life-saving measures were in progress, and the resident was later pronounced deceased. The DON stated she had not identified this incident as deficient practice at the time it occurred and did not realize the magnitude of the problem until it was brought to her attention during the survey. The DON also acknowledged that the facility did not provide additional education to nursing staff on verifying code status and continuing CPR until EMS assumed responsibility. The facility’s administration, including the Administrator and DON, did not have an adequate system in place to identify this deficient practice, determine its root cause, or ensure that nursing staff were trained and competent in verifying residents’ code status and implementing CPR according to orders. The Administrator indicated that when it was discovered that the LPN had not properly determined the resident’s code status and had not continued CPR until EMS arrival, administrative staff should have reviewed the incident to determine the root cause and re-educated nursing staff on the CPR policy and procedure. However, this did not occur prior to the surveyors’ identification of the issue. As a result, the surveyors determined that an Immediate Jeopardy situation existed related to the failure to ensure CPR was initiated and continued for a resident with full code status. A second deficiency involved the facility’s failure to have an adequate system to ensure that licensed nursing staff were made aware of their responsibilities for wound care in the absence of a Treatment Nurse. Multiple residents with pressure ulcers did not receive wound care as ordered by their physicians on days when no Treatment Nurse was assigned. The Treatment Nurse stated that weekend nurses should perform wound care when a Treatment Nurse is not present. Several LPNs reported they did not provide ordered wound care to residents with Stage III and Stage IV pressure ulcers because they were not aware they were responsible for completing wound care on their assigned residents. The DON indicated that on specific dates without a Treatment Nurse, it was the RN Supervisor’s responsibility to remind floor nurses to complete wound care, and a communication sheet instructed the RN Supervisor to remind nurses to perform wound care and sign the Treatment Administration Record. The RN Supervisor stated it was an understood responsibility that floor nurses were responsible for wound care in the absence of a Treatment Nurse, but the interviewed LPNs’ statements showed they had not been effectively informed of this responsibility, resulting in missed wound treatments as ordered. Overall, the facility’s administrative systems did not ensure that critical clinical responsibilities—verifying and acting on residents’ code status with appropriate CPR, and providing ordered wound care in the absence of a Treatment Nurse—were clearly assigned, communicated, and carried out by nursing staff. The DON’s and Administrator’s own interviews confirmed that they had not identified the CPR incident as deficient practice at the time, had not conducted a root cause review, and had not re-educated staff on CPR procedures, and that the process for ensuring wound care coverage on days without a Treatment Nurse relied on informal understandings rather than a consistently implemented system, leading to missed treatments for residents with pressure ulcers.
Removal Plan
- In-service nurses on checking a resident's Code Status in the EMAR and proper procedures for CPR.
- Review all active residents' EMAR to ensure Code Status is posted.
- Identify residents with DNR status.
- In-service all nurses on each shift on checking Code Status in the EMAR and proper procedures for CPR.
- Update the policy and procedure for Review of Resident Deaths.
- Implement a Death Review form for the DON and/or Quality Nurse to complete and immediately initiate changes as needed.
- Require all resident deaths be reviewed by the DON/designee.
- Require unexpected/high-risk deaths be reviewed by the DON/designee.
- Require cases be presented to QAPI at the next scheduled meeting.
- Consult on the death review policy/procedure, how to complete the Death Review form, actions for discrepancies, training nurses to look up code status in the EMAR, and proper CPR procedure.
- QAPI Team to verify the DON is reviewing completed Death Review forms and following through on discrepancies.
- QAPI to monitor Death Review forms.
- QAPI to review all Death Review forms.
Failure to Provide Ordered Daily Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered daily pressure ulcer treatments for three residents with documented pressure injuries. The facility’s Wound Care Protocol required that residents with wounds receive wound care as ordered by the physician. Resident #7 had a care plan and physician’s orders for daily treatment of a Stage IV sacral pressure ulcer, including cleansing with wound cleanser, application of Dakin’s solution–soaked gauze, Santyl ointment, calcium alginate, and a silicone foam border dressing, with dressing changes daily and as needed. On observation, the sacral dressing was dated 03/20/2026, and the Treatment Administration Record (TAR) showed no documented wound care on 03/21/2026 and 03/22/2026. The treatment nurse and the LPNs assigned on those dates each confirmed that the ordered wound care was not provided. Resident #16 had a diagnosis of a Stage II sacral pressure ulcer with physician’s orders, dated 02/18/2026, for daily wound care. The ordered regimen included cleansing with wound cleaner, patting dry, applying Santyl ointment and calcium alginate, and applying Collagenase ointment to the sacral wound every day shift, with a silicone foam border dressing to be changed daily and as needed if soiled or dislodged. The resident’s care plan included an intervention to administer daily wound care as ordered. Review of the March 2026 TAR showed that the daily wound care was not completed on 03/21/2026 and 03/22/2026. On observation, the sacral dressing was dated 03/20/2026, and the treatment nurse, DON, contracted wound care nurse practitioner, and an LPN all acknowledged that the daily wound care ordered by the physician was not performed on those days. Resident #44 had a care plan and physician’s orders for daily treatment of a Stage III right heel pressure ulcer. The orders included cleansing the right heel pressure injury with wound cleanser, patting dry, applying Santyl ointment to the wound bed, covering with a silicone foam border or equivalent dressing, changing the dressing daily and as needed, and applying Collagenase ointment to the right heel every day shift. Review of the March 2026 TAR revealed that wound care to the right heel was not completed on 03/21/2026 and 03/22/2026. Observation showed the right heel dressing was dated 03/20/2026. The treatment nurse, DON, contracted wound care nurse practitioner, and the LPNs assigned on those dates each confirmed that the resident did not receive the ordered daily wound care to the Stage III right heel pressure ulcer on those days.
Failure to Maintain Complete and Accurate Medication, Treatment, and ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, including medication administration, treatments, and activities of daily living (ADL) documentation, for multiple residents. Facility policies required that all medications administered, treatments performed, and services provided be documented in the clinical record. For one resident, physician orders for several medications, including mirtazapine, Seroquel, and ophthalmic solutions, were written to be administered on a specific evening, but the Medication Administration Record (MAR) contained no documentation that these medications were given. The DON confirmed that these medications should have been documented as administered and, in the absence of documentation, the facility could not verify administration. Another resident had physician orders for daily sacral pressure ulcer wound care, use of a low air loss mattress, and pain assessments prior to wound care, as well as a care plan indicating assistance was required for bed mobility, toileting, and transfers. The Treatment Administration Record (TAR) showed no documentation that wound care was provided on several dates, and there was no documentation that the low air loss mattress and pain assessments were provided on multiple dates. ADL documentation for this resident also lacked entries for bed mobility, toileting, and transfers on several days. A contracted wound care nurse stated that these treatments and pain assessments should have been documented as provided. For another resident who required total assistance with bed mobility, ADL records over a multi-day period lacked documentation of bed mobility assistance on numerous shifts; the CNA Supervisor and DON both acknowledged that this documentation was missing and should have been present. Additional residents were affected by similar documentation failures. One resident had multiple medications ordered, including atorvastatin, hydrocortisone suppositories, melatonin, trazodone, Xarelto, and buspirone, to be administered on specified evenings, but the MAR did not show that these medications were administered as ordered; the DON confirmed the lack of documentation. Another resident with orders for heel pressure ulcer wound care, a low air loss mattress, pain assessments prior to wound care, and staff assistance with ADLs had missing documentation on the TAR and ADL records for multiple dates, and both the CNA Supervisor and DON agreed that assistance and treatments should have been documented. A further resident had orders for gabapentin, latanoprost, melatonin, sertraline, and amoxicillin-clavulanate for administration on a specific evening, but the MAR lacked documentation of administration; the DON again confirmed that these medications should have been documented as given. Across all these cases, the facility was unable to verify that ordered medications, treatments, and ADL services were provided due to incomplete and inaccurate records.
Missed Medication Administrations
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #47, based on record review and staff interviews. Physician orders in the resident’s chart included Simethicone 80 mg twice daily, Pataday ophthalmic solution 0.2% daily, Gabapentin 300 mg daily, Meloxicam 15 mg daily, and Sertraline HCl 25 mg daily. Review of the MAR showed multiple missed doses with blank entries and no documented reason, including missed doses of Simethicone, Gabapentin, Meloxicam, and Sertraline in January 2026, as well as missed doses of Pataday ophthalmic solution in March 2026. During interview, an LPN stated she believed the Pataday ophthalmic solution was out of stock, but she did not verify the location of available medication and did not administer it as ordered. The DON stated Simethicone and Pataday were stocked with the facility’s OTC medications and available for use. An RN also stated the non-OTC medications were delivered weekly from the pharmacy and verified the medications were available for administration. The DON later confirmed the medications were available, should have been administered as ordered, and were not.
Failure to Arrange Timely Dental Follow-Up
Penalty
Summary
The facility failed to ensure a resident received dental services as required. Resident #47 was seen by the facility’s contracted dental company for a broken lower left tooth, and the dentist’s plan was to complete a #18 distolingual silver modified atraumatic restorative technique (SMART) filling for the permanent lower left second molar. The resident reported that the broken tooth occurred during a contracted dental cleaning in the facility and that the hygienist told her the tooth would need to be filled at a follow-up appointment. The resident later complained of dental pain, and the Social Services Director emailed the contracted dentist. The dentist requested completion of a triage form so the resident could be seen, but the Social Services Director did not complete the form until more than a month later, which resulted in the resident not being seen during the scheduled dental visit. The DON stated the triage form should have been sent to the contracted dental company before that visit.
Incorrect Enteral Tube Hydration Programming
Penalty
Summary
Resident #4 had an active physician's order dated 03/17/2026 to receive Diabetisource at 45 milliliters per hour continuously with a water flush of 200 milliliters every hour through an enteral tube. During observations on 03/23/2026 and 03/24/2026, the resident's enteral feeding pump was instead set to deliver Diabetisource at 45 milliliters per hour continuously with a water flush of 150 milliliters every 4 hours. On 03/24/2026, an LPN confirmed the pump was programmed for the 150 milliliter every 4 hour flush and acknowledged that the active physician's order called for a 200 milliliter hourly flush. The DON also confirmed the pump was not programmed to administer the ordered 200 milliliter water flush and stated it should have been administered as ordered.
Failure to Coordinate Hospice Documentation
Penalty
Summary
The facility failed to coordinate hospice care and obtain required information from the resident's hospice agency for Resident #23, who was admitted to the facility on 08/18/2025 and admitted for hospice services on 02/24/2026. The facility's Hospice Program policy stated that when a resident participated in hospice, a coordinated plan of care between the facility, hospice agency, and resident/family would be developed and would include directives for managing pain and other uncomfortable symptoms. On the day of admission, the facility nurse was expected to obtain admission orders and a binder from the hospice nurse, but the facility did not have Resident #23's hospice binder. On 03/23/2026 and again on 03/24/2026, the surveyor requested the binder from the DON and then from an LPN, and the LPN stated the facility did not have one and should have. The hospice agency's medical records representative stated the binder should be created by the hospice agency and brought to the facility by the hospice nurse, and both the DON and the Administrator later acknowledged that the facility did not have the binder and should have had it available.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly linked to the facility's failure to meet required standards for resident care in these domains.
Inaccurate Documentation of Resident Care in Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two of three sampled residents. For one resident, a physician's order required suprapubic catheter care to be performed every shift. However, review of the electronic Medication Administration Record (eMAR) showed that an LPN documented the catheter care as completed, but later admitted in an interview that she did not perform the care during her shift as ordered. For another resident, physician's orders required both suprapubic catheter care every shift and the use of a pressure relieving cushion on the resident's wheelchair to prevent skin breakdown. The eMAR reflected that catheter care and the presence of the cushion were documented as completed by multiple LPNs on several shifts. However, observation revealed the resident was sitting in the wheelchair without the cushion, and the resident reported not having had a cushion in months. One LPN admitted to documenting catheter care and the presence of the cushion without verifying or performing these tasks. The Director of Nursing confirmed the documentation was inaccurate, and the Administrator did not dispute the findings.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide effective communication training to direct care staff members, as evidenced by record reviews and staff interviews. Personnel records for five certified nursing assistants (CNAs) showed that none had received the required effective communication training since their respective dates of hire. Interviews with the CNA Supervisor confirmed that effective communication training was not included in either new hire orientation or ongoing in-service training. The Director of Nursing also confirmed that these staff members had not received the necessary training.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all direct care staff as required. Record reviews showed that five sampled Certified Nursing Assistants (CNAs), each with documented hire dates in 2025, did not receive QAPI training. Interviews with the CNA Supervisor revealed that QAPI training was not included in either new hire orientation or ongoing in-service education. The Director of Nursing confirmed that these staff members had not received the required QAPI training.
Facility Assessment Lacked Required Input and Census Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that included active participation from direct care staff, such as a Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA), as well as a resident and resident representatives. The assessment also did not document the current number of residents in the facility at the time it was completed. These omissions were confirmed through review of the facility assessment and an interview with the administrator, who acknowledged that the required individuals were not involved in the assessment's development and that the average daily census was not included.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information at the beginning of each shift for three consecutive days. Observations on each of these days revealed that the posted nurse staffing information did not include the facility's daily census or the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). These omissions were confirmed during interviews with the Director of Nursing and the Administrator, who acknowledged that the staffing reports lacked the necessary details as required.
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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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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