Magnolia Manor Nursing And Rehab Ctr, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 1411 Claiborne Avenue, Shreveport, Louisiana 71103
- CMS Provider Number
- 195406
- Inspections on file
- 26
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Magnolia Manor Nursing And Rehab Ctr, Llc during CMS and state inspections, most recent first.
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 multiple medical and psychiatric diagnoses, including schizoaffective disorder and a moderately impaired BIMS score, was started on Depakote 125 mg BID for mood stabilization. The MAR showed the medication was administered as ordered, but the resident’s responsible party reported she was not informed of the new medication and only learned of it when the resident later refused a blood draw for a Depakote level. Review of the medical record, including progress notes, showed no documentation of notification to the responsible party, and the DON confirmed that notification should have occurred and that there was no evidence it had been done.
A resident with severe cognitive and physical impairments was physically and verbally abused by a CNA during care, as captured on surveillance video. The CNA forcefully handled the resident's limbs, used profane language, and expressed refusal to continue care, causing the resident distress. The incident was not immediately reported by staff, and was only brought to administration's attention after the resident's family provided video evidence.
A CNA provided care to a resident in a hurried and disrespectful manner, making dismissive comments and speaking about the resident to other staff during care. The resident, who had impaired mobility and was resistive to care, expressed discomfort during the interaction. Leadership confirmed that the care provided did not promote dignity or quality of life.
A CNA failed to recognize and report physical and verbal abuse by another CNA during incontinent care for a resident with significant cognitive and physical impairments. The abuse, which included rough handling and use of profane language, was not reported to administration as required by facility policy, and was only discovered after a family member provided video evidence. The deficiency involved a breakdown in timely internal reporting of suspected abuse.
A facility failed to monitor a resident's edema while the resident was receiving Furosemide, a diuretic, for chronic pulmonary edema and heart failure. Despite the prescription, there was no documentation of edema monitoring, as confirmed by an LPN and the DON.
A facility failed to provide necessary respiratory care by not cleaning a resident's oxygen concentrator filter weekly as required. The resident, who required continuous oxygen due to conditions like pneumonia and COPD, was observed with a concentrator filter containing a gray film. An LPN admitted to being unaware of the cleaning requirement, indicating a lapse in following the facility's policy.
A resident with cognitive impairments was physically abused by a staff member in a LTC facility. The incident involved the resident, who was in a wheelchair, and a staff member identified as S7 Sunshine Aide. Surveillance video showed the aide hitting the resident with a plastic cup during an altercation. The resident, known for aggressive behaviors, was assessed with no physical injuries but experienced severe psychosocial harm.
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 Notify Responsible Party of New Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a new medication order. The resident was admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, bipolar II disorder, type 2 diabetes mellitus, schizoaffective disorder bipolar type, generalized anxiety disorder, unspecified convulsions, unspecified conjunctivitis, a left hip contracture, and a sacral pressure ulcer. The resident’s MDS showed a BIMS score of 9, indicating moderately impaired cognition. In June 2025, the physician ordered Depakote 125 mg by mouth twice daily for mood stabilization related to schizoaffective disorder, bipolar type, with a start date of 06/30/2025, and the June 2025 MAR documented that Depakote administration began on that date. During a telephone interview, the resident’s responsible party reported she was not notified when Depakote was started and only became aware of the medication on 07/24/2025 when the resident refused a blood draw for a Depakote level. Review of the resident’s medical record, including progress notes, did not reveal any documentation that the responsible party had been informed of the initiation of Depakote in June 2025. In an interview, the DON confirmed that the responsible party should have been notified of the Depakote order and acknowledged she could not provide any evidence that such notification occurred.
Failure to Protect Resident from Physical and Verbal Abuse by CNA
Penalty
Summary
A cognitively impaired resident with multiple neurological and psychiatric diagnoses, including hemiplegia, dementia, anxiety disorder, bipolar disorder, and schizophrenia, was subjected to physical and verbal abuse by a Certified Nurse Assistant (CNA) during morning care. The resident required extensive two-person assistance for all activities of daily living except feeding and was always incontinent of urine and bowel. The incident was captured on a surveillance video, which showed the CNA pulling down on the resident's contracted leg, forcefully snatching the resident's arm from the side rail, and aggressively removing the resident's diaper. The resident verbally expressed pain during the incident. In addition to the physical actions, the CNA was heard cursing at the resident and making statements indicating frustration and refusal to continue care. The resident responded by apologizing repeatedly, suggesting distress and possible psychosocial harm. The facility's policy clearly prohibits any form of abuse, including physical and verbal abuse, and outlines specific procedures for the detection, prevention, and reporting of such incidents. Interviews with staff and the resident's family confirmed the abusive behavior observed in the video. The CNA involved was not the resident's primary caregiver but was assisting another CNA at the time. The second CNA present acknowledged that the actions observed constituted abuse and should have been reported immediately. The incident was not reported until the resident's sister brought it to the attention of facility administration, indicating a failure in immediate identification and reporting of abuse as required by facility policy.
Failure to Provide Dignified and Respectful Care During Resident Assistance
Penalty
Summary
A deficiency occurred when a CNA provided care to a resident in a hurried and disrespectful manner, as captured on a surveillance video. The CNA made dismissive comments, such as 'Just nothing else better to do' and 'waste it; I don't care; I don't have nothing to do with that,' while attempting to remove a cup of juice from the resident's hand. The resident, who had impaired physical mobility, a self-care deficit, and was known to be resistive to care due to anxiety, moved their hand away, and later expressed discomfort by hollering 'you're hurting me' as linens were removed forcefully from under their leg. The CNA also spoke about the resident to other staff during care, further compromising the resident's dignity. The resident's care plan included specific interventions, such as using a draw sheet for turning and repositioning per family request, and required turning and repositioning every two hours, as well as incontinence care. Despite these documented needs, the care provided was not consistent with promoting the resident's dignity or quality of life. The CNA's actions included rushing through care, speaking disrespectfully, and engaging in conversations about the resident with other staff in the resident's presence. Interviews with facility leadership confirmed that care should be provided at the resident's eye level, without hurried actions or staff conversations unrelated to the resident's care. The Director of Nursing and other administrators acknowledged that the CNA's behavior was inappropriate and did not uphold the resident's right to dignity during care.
Failure to Timely Report and Recognize Resident Abuse During Care
Penalty
Summary
A deficiency occurred when the facility failed to implement its policies and procedures to ensure that an allegation of abuse was reported to administration in a timely manner. During incontinent care, a Certified Nurse Assistant (CNA) engaged in both physical and verbal abuse toward a resident, which was not immediately recognized or reported by another CNA present during the incident. The facility's policy required that any abuse or suspicion of abuse be reported immediately to the Administrator or designee, but this did not occur as required. The resident involved had significant medical conditions, including neurological disorders, hemiplegia, dementia, anxiety, bipolar disorder, schizophrenia, muscle wasting, and cognitive decline. The resident was dependent on staff for bed mobility and transfers, and was always incontinent of bladder and bowel. During the incident, surveillance video captured the CNA pulling on the resident's contracted leg, causing the resident to express pain, and forcefully removing the resident's arm from a side rail. The CNA also used profane language and expressed frustration during care, while the resident repeatedly apologized. The other CNA present did not intervene or report the abuse at the time. The failure to report the abuse was later acknowledged by the second CNA after receiving in-service training on identifying and reporting abuse. The incident was only brought to the attention of administration after the resident's sister presented video evidence. The delay in reporting and failure to follow internal reporting procedures constituted the deficiency cited in the report.
Failure to Monitor Edema in Resident on Diuretic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically in the case of a resident with chronic pulmonary edema and chronic diastolic heart failure. The resident was prescribed Furosemide, a diuretic, to be taken twice daily. However, the facility did not monitor the resident's edema as required. This lack of monitoring was confirmed during an interview with an LPN, who acknowledged the absence of documentation for edema monitoring. The Director of Nursing also confirmed that the resident was not monitored for edema, which should have been done.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards for a resident who required continuous oxygen support. The deficiency was identified during a review of the facility's practices and an observation of the resident's oxygen concentrator. The facility's policy mandates that humidifier bottles, cannulas, and oxygen tubing be changed at least once weekly and dated, and that the concentrator filter should be cleaned weekly or as needed. However, observations revealed that the filter on the resident's oxygen concentrator contained a fine gray film, indicating it had not been cleaned as required. The resident, who was admitted with diagnoses including pneumonia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen, was observed wearing continuous oxygen at 2 liters via nasal cannula. Despite the resident's continuous use of oxygen, the filter remained uncleaned over multiple observations. An LPN interviewed during the survey acknowledged the dirty condition of the filter and was unaware of the requirement to clean it, highlighting a lapse in adherence to the facility's respiratory care policy.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse and psychosocial harm by a staff member. The incident involved a cognitively impaired resident who was observed on surveillance video being physically abused by a staff member, identified as S7 Sunshine Aide. The aide was seen hitting the resident on her hands and forearm with a hard plastic kitchenware cup. This incident occurred when the resident, who was in a wheelchair, approached a coffee cart and picked up cups, leading to an altercation with the aide. The resident involved had a history of cognitive impairments, including vascular dementia with behavioral disturbances, and was known to exhibit aggressive behaviors. The resident's medical record indicated severe cognitive impairment with a BIMS score of 5 out of 15. The resident's care plan included interventions for managing aggressive behavior, such as using a calm voice and avoiding arguments. Despite these measures, the resident engaged in a physical altercation with the aide, who reacted by hitting the resident. The incident was captured on surveillance video, which showed the aide and the resident swinging at each other, with the aide making contact with the resident's arm. Interviews with staff members confirmed the altercation, and the aide was subsequently sent home. The facility's investigation revealed that the aide's actions constituted physical abuse, and the resident was assessed with no physical injuries but was determined to have experienced severe psychosocial harm due to the incident.
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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