Maison Du Monde Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abbeville, Louisiana.
- Location
- 4000 Rodeo Road, Abbeville, Louisiana 70510
- CMS Provider Number
- 195567
- Inspections on file
- 19
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Maison Du Monde Living Center during CMS and state inspections, most recent first.
A resident with moderate hearing impairment and intact cognition, care planned as needing hearing aids, did not receive appropriate assistive devices after the facility failed to follow up with community resources. Social services knew the resident could not afford a hearing program’s application fee and that referrals had been made by an ENT to outside providers for assistance with hearing devices, including an evaluation that was never scheduled. Despite this and the facility policy assigning social services responsibility for obtaining outside services, the Social Services Director did not follow up with the community providers or seek alternative assistance after family involvement lapsed, leaving the resident waiting for hearing aids for months.
Two residents with cognitive and psychiatric conditions engaged in repeated physical altercations on consecutive days after an accusation of stolen soda. On the first day, a resident using a walker accused a wheelchair user of theft, after which the wheelchair user rammed the walker and struck the other resident's leg while a CNA was pushing her away. On the next day, the resident with the walker kicked the wheelchair user in the leg as she passed in the hallway, later admitting she did so in retaliation for the prior day's incident. An LPN documented both events, and the administrator was notified, but the facility did not effectively prevent or protect the residents from physical abuse by each other, contrary to its abuse prevention policy.
A resident was discharged from the facility without a required discharge summary being completed, contrary to the facility’s own policy that mandates a discharge summary and post-discharge plan for anticipated discharges to a private residence or another nursing care facility. Record review showed the absence of any discharge summary in the resident’s medical record, and the SSD confirmed during interview that no discharge summary had been completed.
The facility failed to document and investigate complaints about inconsistent ice distribution voiced during resident council meetings. Despite the facility's policy requiring investigation and reporting of grievances, the Activity Director did not document the complaints, and the CNA Supervisor was unaware of them. Residents expressed dissatisfaction with the inconsistency, highlighting a deficiency in addressing resident concerns.
The facility failed to notify a physician of abnormal CBG levels for a resident with diabetes and did not document a choking incident in another resident's care plan. The first resident had multiple instances of high CBG levels without physician notification, while the second resident, who was cognitively intact, experienced a choking incident that was not addressed in their care plan. Both deficiencies were confirmed by facility staff.
The facility failed to follow recipes for pureed diets, affecting 12 residents. Observations showed cooks preparing pureed meals without measuring ingredients, resulting in improper consistency. Dietary staff lacked training and access to recipes, as confirmed by the RD. This deficiency could impact residents' nutritional intake.
The facility failed to meet professional standards for two residents receiving hospice care. One resident's hospice binder was not updated with current nurse visit notes and certification, and staff were unclear about responsibility for updates. Another resident experienced multiple high blood sugar levels without the hospice agency being informed, as confirmed by the Corporate Nurse and Hospice Agency Director of Nursing.
A facility failed to ensure a resident was safe to self-administer medication, as required by policy. The resident, with moderate cognitive impairment, was observed with medication at her bedside without an assessment or care plan for self-administration. An LPN confirmed leaving the medication, and the DON acknowledged the lack of necessary documentation, indicating a failure to adhere to the facility's policy.
The facility failed to report injuries of unknown source for two residents with severe cognitive impairment. One resident was found on the floor with a left arm fracture and a UTI, while another was found with a head bruise and a left wrist fracture. Both incidents were not reported to the state agency as required.
The facility failed to notify the State LTC Ombudsman of facility-initiated transfers for two residents, as required. A resident with Alzheimer's and another with dementia were transferred to the hospital multiple times, but these transfers were not recorded in the Emergency Transfer Log. The BOM, responsible for the log, was unaware that even short-term transfers needed to be reported, potentially affecting the entire census of 112 residents.
A facility failed to administer enteral feeding at the ordered rate for a resident with Alzheimer's, dementia, and a gastrostomy. The policy required checking the rate against the order, but an LPN confirmed the feeding was running at 45 ml/hour instead of the ordered 44 ml/hour, potentially affecting other residents with tube feedings.
A facility failed to maintain accurate medical records by not ensuring a resident's care plan reflected the need for weekly weight monitoring, despite significant weight loss and a low BMI. The care plan inaccurately documented monthly weighing, which was confirmed by an MDS/LPN during a review. This discrepancy could potentially affect the facility's entire census.
A facility failed to ensure proper use of PPE during biohazard trash removal. A Treatment Nurse was observed handling a soiled glove and biohazard bag without gloves and placed the bag on a treatment cart. The DON confirmed the nurse should have used PPE and not placed the bag on the cart.
A facility failed to ensure proper monitoring and reporting of wound care, leading to an Immediate Jeopardy situation. A resident with multiple health issues, including Peripheral Vascular Disease and Diabetes, experienced a significant deterioration in a right foot wound and developed a new wound on the left foot, both of which became infested with maggots. LPNs conducted assessments without oversight from a registered nurse, resulting in a lack of notification to the physician about the worsening condition.
The facility failed to provide an effective wound prevention program due to the lack of RN oversight in monitoring weekly body/skin assessments and wound evaluations conducted by LPNs. This deficiency led to an Immediate Jeopardy situation when a resident's deteriorating foot wounds were not reported, resulting in maggot infestation.
A facility failed to notify a resident's responsible party and healthcare providers about a worsening right foot wound. The resident had multiple health issues, and the wound significantly increased in size over several weeks. Despite the deterioration, there was no documentation of notification, and interviews confirmed the responsible party and nurse practitioner were not informed. The facility's policy lacked clarity on reporting responsibilities.
Failure to Follow Up on Community Resources for Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities by not following up with community resources. The resident, who was cognitively intact with a BIMS score of 13 and had moderate hearing difficulty requiring increased volume and distinct speech, had a care plan problem for altered communication related to being hard of hearing and recurrent cerumen impaction, with a noted need for hearing aids. The care plan documented that paperwork for hearing aids had been sent with the family but not returned due to financial issues. In an interview, the resident reported having waited months for hearing aids and stated the facility told her they were waiting on a company to get the devices, while the surveyor had to speak very loudly for the resident to hear. Record review and interviews with the Social Services Director (SSD) showed that the resident had been seen by an ENT specialist and was recommended for a hearing program that required an application fee the resident could not afford. The SSD documented that the ENT office stated the resident could not participate in the program without paying the fee and that the resident was referred to another community provider for assistance with hearing devices. The SSD later learned that this community provider saw the resident and referred her to a second provider for an evaluation to assist with obtaining hearing aids, but the evaluation was never scheduled. The SSD acknowledged she did not follow up with either community provider after communication with the family ceased and did not pursue other assistance or resources for hearing aids from that time until questioned by the surveyor, despite facility policy assigning social services responsibility for making referrals and obtaining needed services from outside entities.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during resident-to-resident altercations on consecutive days. Facility policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse, and that administration will protect residents from abuse by anyone, including other residents, and protect residents during abuse investigations. Despite this policy, one cognitively intact resident with bipolar disorder and depression with psychotic features (Resident #81) and another resident with Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder (Resident #2) engaged in physical aggression toward each other without effective prevention of further contact. On the first day, documentation and interviews showed that Resident #81 was walking in the hallway with a walker when Resident #2, in a wheelchair, passed by. Resident #81 accused Resident #2 of stealing her soda, and Resident #2 then ran her wheelchair into Resident #81's walker. A CNA intervened and began pushing Resident #2 back to her room, during which Resident #2 reached out and hit Resident #81 on the leg. Nursing notes and the facility incident report documented that both residents were then taken to their rooms and that no injuries were observed at that time. The LPN and CNA interviews were consistent in describing that Resident #2 physically struck Resident #81 during the separation. On the following day, the same LPN documented that Resident #2 was again propelling herself in the hallway when Resident #81 came out of her room and kicked Resident #2 in the leg as she passed. Resident #2 yelled out in response, and when questioned, Resident #81 admitted to kicking Resident #2, stating she did so because Resident #2 had hit her the previous day and stolen her soda and that she was not sorry. The LPN assisted Resident #2 back to her room while Resident #81 remained in her room to finish breakfast. The administrator confirmed being notified of both physical altercations at the times they occurred and that there were no injuries, but the incidents demonstrated that the facility did not effectively protect either resident from physical abuse by the other resident as required by its abuse prevention policy.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for one of three closed records reviewed. The facility’s policy, last reviewed on 04/09/2025, states that when a discharge is anticipated to a private residence or another nursing care facility, a discharge summary and post-discharge plan must be developed to assist the resident’s adjustment, and that a copy of the discharge summary must be provided to the resident, the receiving facility, and filed in the resident’s medical record. Record review showed that Resident #123 was admitted on an unspecified date and discharged on 11/07/2025, but the medical record contained no documentation of a completed discharge summary. During a record review and interview on 01/28/2026 at 2:06 p.m., the Social Services Director confirmed that the resident had been discharged on 11/07/2025 and further confirmed that a discharge summary was not completed for this resident. No additional medical history or condition details for the resident at the time of discharge were documented in the report.
Failure to Document and Investigate Resident Complaints
Penalty
Summary
The facility failed to document, investigate, and maintain records of complaints voiced during resident council meetings held in July and October 2024. The facility's policy requires that upon receipt of a grievance or complaint, the designee must review and investigate the allegations and submit a written report of the findings to the administrator within five working days. However, during interviews with residents and staff, it was revealed that complaints about the inconsistency of ice being passed to residents were not documented or investigated as grievances. The Activity Director admitted to not writing up the complaints because only one resident complained in each meeting, and instead, she provided ice and water to the resident and informed the CNA supervisor. Residents expressed dissatisfaction with the inconsistency of ice distribution, stating that while the issue would be temporarily resolved after being reported, it would soon revert to the previous state of neglect. One resident mentioned that having a schedule for ice and water distribution would prevent them from feeling like they were bothering staff. The CNA Supervisor could not recall any complaints about the issue and confirmed there was no documentation of such complaints. This lack of documentation and investigation of grievances is a deficiency in honoring residents' rights to voice concerns and have them addressed appropriately.
Failure to Notify Physician and Document Choking Incident in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For one resident with end-stage heart failure, unspecified dementia, and type 2 diabetes mellitus, the facility did not notify the physician of abnormal capillary blood glucose (CBG) levels as ordered. The resident's medical records showed multiple instances of CBG levels exceeding 401, which required immediate notification to the physician according to the facility's policy. However, there was no documentation indicating that the physician was informed of these abnormal results, as confirmed by the Corporate Nurse during an interview. Another resident, who was cognitively intact and had diagnoses including paraplegia and gastroesophageal reflux disease, experienced a choking incident. The resident choked on food and was subsequently transferred to the emergency room for evaluation due to esophageal obstruction. Despite this significant event, the resident's comprehensive care plan did not include a focus area or interventions related to the choking incident. Both the Minimum Data Set Coordinator and the Director of Nursing confirmed that the incident should have been documented in the care plan with appropriate interventions, but it was not.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed, which had the potential to negatively impact the dining experience and nutritional intake of 12 residents receiving pureed meals. Observations revealed that S4Cook prepared pureed rice without measuring the water or rice, relying on guesswork to achieve the desired consistency. Similarly, S5Cook prepared pureed bread and beans that resulted in a thin liquid consistency, which was not appropriate for a pureed diet. Both cooks demonstrated a lack of adherence to the facility's puree recipe guidelines. Interviews with dietary staff, including S6DS, S8Cook, and S9DS, revealed a lack of training on how to properly puree foods using recipes. S6DS confirmed that the puree recipe liquid addition quick guide was not helpful, as it lacked specific measurements for certain foods. Additionally, S7RD, the registered dietician, confirmed that puree recipes were not available in the main kitchen for cooks to reference. This lack of training and resources contributed to the improper preparation of pureed meals, potentially affecting the nutritional needs of the residents.
Deficiencies in Hospice Care Coordination and Communication
Penalty
Summary
The facility failed to provide services that met professional standards for two residents receiving hospice care. For one resident, the facility did not collaborate effectively with the hospice agency to ensure that the hospice nurse's visit notes and certification were up-to-date in the resident's hospice binder. The last certification period was noted to be outdated, and the last hospice nurse visit notes were several months old. During interviews, facility staff were unclear about who was responsible for ensuring the hospice binder was updated, with the Director of Nursing indicating that it was the hospice agency's responsibility. For the second resident, the facility failed to communicate with the hospice agency regarding the resident's high blood sugar levels. The resident had multiple occurrences of critically high blood glucose levels over several months, yet there was no documentation indicating that the hospice agency was informed of these abnormal levels. The Corporate Nurse confirmed the lack of communication, and the Hospice Agency Director of Nursing stated that the hospice should have been notified of such significant changes in the resident's condition.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The policy mandates that residents can self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe. However, there was no assessment, physician's order, or care plan for the resident to self-administer medication. The resident, who had a diagnosis of Gastro-Esophageal Reflux Disease and a BIMS score indicating moderate cognitive impairment, was observed with a medicine cup containing medication on her bedside table, which she intended to take herself. An LPN confirmed that she had left the medication, identified as Mylanta, on the resident's bedside table, acknowledging that the resident preferred to take it in intervals. The Director of Nursing confirmed that the resident's record lacked the necessary documentation to support self-administration of medication, and it was inappropriate for the medication to be left at the bedside. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, compromising the safety and care of the resident.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report alleged injuries of unknown source to the State Survey Agency within the required two-hour timeframe for two residents. Resident #84, who has severe cognitive impairment, was found on the floor outside her room with a fracture to her left arm and was diagnosed with a urinary tract infection. The incident was not reported to the state agency as required by the facility's policy. Similarly, Resident #113, also with severe cognitive impairment, was found sitting on the floor with a head bruise and a fracture to his left wrist. This incident was also not reported to the state agency. Both residents were unable to recall the events leading to their injuries, and the Director of Nursing confirmed that these incidents should have been reported but were not.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for two residents, which is a requirement for ensuring proper oversight and resident rights. Resident #84, who had diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder, was transferred to the hospital on multiple occasions, specifically on 10/15/2024, 11/08/2024, and 11/17/2024. However, these transfers were not recorded in the Emergency Transfer Log for October and November 2024, which is used to notify the Ombudsman. Similarly, Resident #113, with diagnoses including dementia, depression, and repeated falls, was transferred to the hospital on several dates, including 08/19/2024, 10/10/2024, 10/12/2024, 11/28/2024, and 12/02/2024, but these were also not documented in the Emergency Transfer Log. The Business Office Manager (BOM), responsible for maintaining the Emergency Transfer Log and notifying the Ombudsman, confirmed the omissions during an interview and record review. The BOM was unaware that facility-initiated transfers, even those lasting less than 24 hours, needed to be included in the log sent to the Ombudsman. This oversight in documentation and notification could potentially affect the facility's entire census of 112 residents, as it undermines the regulatory requirement to inform the Ombudsman of all facility-initiated transfers.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that the enteral feeding for a resident was infused at the ordered rate, which was a deficiency identified during a survey. The facility's policy on enteral feedings required checking the rate of administration against the order before administration. However, an observation and interview with an LPN revealed that the enteral feeding for a resident with Alzheimer's disease, unspecified dementia, dysphagia, chronic systolic heart failure, and a gastrostomy was running at 45 ml/hour, contrary to the ordered rate of 44 ml/hour. This discrepancy was confirmed by the LPN, indicating a failure to adhere to the prescribed feeding rate, which had the potential to affect other residents receiving tube feedings in the facility.
Inaccurate Documentation of Care Plan for Resident
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by not ensuring that the comprehensive care plan for a resident was accurately documented. The resident in question was admitted with diagnoses including paraplegia, spinal stenosis, muscle wasting and atrophy, and ileus. A review of the resident's progress notes revealed significant weight loss over several months, with a current weight of 121.2 pounds and a BMI of 18.4, indicating an underweight status. The resident's weight loss was documented with specific percentage changes compared to previous weights, triggering a need for weekly weight monitoring until stabilization. However, the comprehensive care plan for the resident only included an intervention to weigh the resident monthly, which was inconsistent with the need for weekly monitoring as indicated by the progress notes. This discrepancy was confirmed during a record review and interview with the Minimum Data Set Coordinator/LPN, who acknowledged that the care plan did not accurately reflect the required frequency of weight monitoring. This failure to document the necessary intervention in the care plan represents a deficiency in maintaining accurate medical records, potentially affecting the facility's entire census of 112 residents.
Inadequate Use of PPE During Biohazard Trash Removal
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not ensuring staff used personal protective equipment (PPE) according to accepted standards during biohazard trash removal. During an observation on Hall A, a treatment cart was found with a trash can attached, containing a red biohazard trash bag. A partially discarded blue glove was observed hanging halfway out of the bag. The Treatment Nurse, after completing her treatments, was seen removing the glove and the biohazard bag without wearing gloves, and then placing the biohazard bag on top of the treatment cart. The Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed that the Treatment Nurse should have donned gloves before handling the soiled glove and biohazard materials. Additionally, the biohazard bag should not have been placed on top of the treatment cart. This incident highlights a lapse in following the facility's policy on the use of gloves to prevent the spread of infection and protect staff from potentially infectious materials.
Failure to Monitor and Report Wound Deterioration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not have a registered nurse monitor weekly body/skin assessments and wound care evaluations, which were performed only by Licensed Practical Nurses (LPNs) for ten sampled residents with wounds. This oversight led to an Immediate Jeopardy situation when the facility failed to notify the physician of a deteriorating right foot wound and did not identify and report a new wound on the left foot of Resident #2, resulting in an infestation of maggots in both feet. Resident #2 was admitted to the facility with multiple diagnoses, including Hemiplegia, Schizoaffective Disorder, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus, among others. The resident's comprehensive care plan noted a potential for skin breakdown due to decreased mobility and other factors. Despite having a physician's order for daily wound care on the right foot, the wound evaluations showed significant deterioration from early April to late April, with no documentation of notification to the physician or nurse practitioner. Additionally, body audit/skin assessments failed to identify a new wound on the left foot, which was later discovered to be infested with maggots. Interviews with facility staff revealed that the LPNs were responsible for conducting body audit/skin assessments and reporting any changes to the wound care nurse, who was also an LPN. However, there was no oversight by a registered nurse, and the wound care nurse did not assess the left foot or lower extremity as she was only responsible for active wounds. The Director of Nursing confirmed that the assessments were not conducted properly, and there was a lack of documentation regarding changes in the resident's condition. This failure to monitor and report changes in the resident's wounds led to severe consequences for Resident #2.
Lack of RN Oversight in Wound Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to administer an effective wound prevention program with appropriate professional oversight, leading to a deficiency in the care provided to residents. Specifically, the facility did not ensure that Registered Nurses (RNs) monitored weekly body/skin assessments and wound evaluations performed by Licensed Practical Nurses (LPNs) for ten sampled residents. This lack of oversight had the potential to cause severe harm, injury, or death to 117 residents who received weekly unmonitored body/skin assessments and wound care. The deficiency was highlighted by an Immediate Jeopardy situation when the facility failed to notify a physician of a deteriorating right foot wound and did not identify and report a new wound on a resident's left foot, resulting in an infestation of maggots on both feet. Interviews and record reviews revealed that the facility's LPNs were responsible for conducting all residents' body audits/skin assessments and wound evaluations without RN oversight. The Director of Nursing (DON) confirmed that neither she nor the Assistant Director of Nursing reviewed these assessments. Additionally, the data entry clerk, an LPN, was responsible for ensuring that all assessments and evaluations were documented in the residents' charts. The Corporate Nurse was aware that weekly skin and wound evaluations were conducted by LPNs without RN monitoring, which contributed to the deficiency.
Failure to Notify of Worsening Wound Condition
Penalty
Summary
The facility failed to notify the responsible party, nurse practitioner, and physician of a resident's deteriorating right foot wound in a timely manner. The resident, who was admitted with multiple diagnoses including hemiplegia, schizoaffective disorder, and peripheral vascular disease, had a wound on the right dorsum foot that significantly increased in size over several weeks. Despite the wound's worsening condition, there was no documentation of notification to the resident's responsible party or healthcare providers. Interviews revealed that the resident's responsible party was unaware of the wound's deterioration, and the nurse practitioner was not informed of the worsening condition. The wound care nurse acknowledged the wound's increasing maceration and drainage but confirmed that no notification was made to the responsible party. The facility's policy on wound prevention did not specify which professional discipline should perform assessments or to whom changes should be reported, contributing to the communication breakdown.
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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