Mary Anna Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wisner, Louisiana.
- Location
- 125 Turner Street, Wisner, Louisiana 71378
- CMS Provider Number
- 195605
- Inspections on file
- 18
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 8 (2 serious)
Citation history
Health deficiencies cited at Mary Anna Nursing Home during CMS and state inspections, most recent first.
A resident with hemiplegia, multiple chronic conditions, and wheelchair dependence was transported by a CNA who failed to apply the van’s restraining lap belt, did not stop to reposition the resident after being told she was sliding, and left her unattended in the van while stopping at a personal residence. During this time, the resident slid from her wheelchair onto the floor of the van. The CNA returned, did not call the facility or seek assistance, and drove the resident back while she remained on the floor, without reporting when the fall occurred or how long the resident had been on the floor. The facility’s investigation, referencing existing abuse/neglect, fall management, and transportation safety policies and prior staff training, substantiated neglect and the situation was cited as Immediate Jeopardy.
A wheelchair-dependent, cognitively intact resident with multiple comorbidities, including hemiplegia, CHF, DM with neuropathy, chronic pain, cervical spinal stenosis, and COPD, was transported in the facility van by a CNA who had been trained on transportation safety policies requiring use of restraints and seat belts. The CNA did not apply the van’s restraining lap belt and did not reposition the resident after the resident reported sliding down in the wheelchair. The CNA then stopped at her personal residence, left the resident unattended in the van, and during this time the resident slid from the wheelchair onto the van floor. On returning to the van, the CNA found the resident on the floor but did not call the facility for assistance and drove back with the resident still on the floor, where staff later assessed and lifted the resident from the van floor. Surveyors determined this constituted an Immediate Jeopardy situation.
Failure to Implement Fall Care Plan Intervention: A resident with dementia, severe cognitive impairment, and high fall risk had a fall care plan intervention to keep a reacher within reach, but staff did not identify it as an intervention and the device was not observed with the resident. The resident stated she did not have the reacher, and the DON confirmed there was no documentation supporting that it was in place per the care plan.
A resident with cancer, dysphagia, and DM with CKD had a significant 7.11% weight loss after hospitalization, but the facility did not follow its weight loss management policy. Staff did not document timely notification of the RD, MD, or RP, did not hold the required IDT review, did not document weekly weights or monthly follow-up, and no new nutrition interventions were in place when the resident later was recommended sugar free health shakes that were not provided with meals.
Two residents received Voltaren 1% gel without the dosage ordered by the physician, including one resident with severe cognitive impairment and another with moderate cognitive impairment. In addition, staff did not document notifying the physician of a resident’s edema and incoherent status, did not complete a post-nebulizer assessment, and did not follow the care plan for daily weights and monitoring of breath sounds.
Residents did not receive mail on Saturdays because the Office Manager collected mail from the PO box Monday through Friday only and no staff member was assigned to check the box on Saturdays. A resident reported receiving mail only on weekdays, and the Administrator confirmed residents were not able to receive mail on Saturdays.
Nebulizer tubing and face mask were found connected to a nebulizer machine beside a resident’s bed, not dated, and not stored in a plastic bag when not in use. The resident had active nebulizer orders for ipratropium-albuterol and PRN albuterol, and the DON confirmed the tubing should be dated and properly stored per policy.
Failure to Implement Enhanced Barrier Precautions: The facility did not consistently follow EBP for two residents. One resident with a surgical wound and additional wounds had no EBP signage posted outside the room, and the DON confirmed the sign should have been there. Another resident with a PEG tube had an order for gown and glove use during feeding tube care, but an LPN administered meds via PEG without donning a gown.
The facility failed to ensure residents were free from physical restraints used for convenience, as bolsters were applied without consent, physician's orders, or assessments. This affected four residents with cognitive impairments and mobility issues, highlighting a systemic issue in following restraint policies.
A resident with Alzheimer's and a history of falls experienced multiple falls due to inadequate interventions. Despite being dependent on staff and having severely impaired cognitive skills, the facility's interventions, such as reminders to balance and wear well-fitted shoes, were confirmed as inappropriate by the DON. The resident's falls included incidents with a walker and slipping in urine.
The facility failed to assess the risk of entrapment from bed rails for three residents before installation, despite their severe cognitive impairments and medical conditions. The facility's policy requires such assessments and informed consent, but documentation was lacking, as confirmed by the administrator.
Resident Neglect During Unsafe Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transportation in the facility van. A CNA responsible for transport did not follow the facility’s transportation safety policies and procedures, including the requirement to properly secure residents with restraining seatbelts. The resident involved had multiple medical diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic heart failure, type 2 diabetes with autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. The resident was cognitively intact with a BIMS score of 15 and was dependent on a wheelchair for mobility and staff assistance for transfers using a lift. During a return trip from a physician appointment, the CNA failed to attach the van’s restraining lap belt across the resident’s lap. While en route, the resident told the CNA that she felt like she was sliding down in her wheelchair. Despite this verbal report, the CNA did not stop the van to reposition the resident or correct the lack of restraint. Instead, the CNA continued driving until reaching her personal residence. The CNA then went inside her residence, leaving the resident unattended in the van and still not properly secured or repositioned. While the CNA was inside her personal residence, the resident slid out of her wheelchair onto the floor of the transportation van. When the CNA returned to the van, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. The CNA then drove approximately 15.3 miles back to the facility with the resident remaining on the floor of the van. Upon arrival, the CNA did not inform facility staff when the fall had occurred or how long the resident had been on the floor. The resident was later assessed with no injuries, and the facility’s investigation substantiated neglect based on these events and the CNA’s failure to follow established policies on abuse, neglect, fall management, and transportation safety. The facility’s policies in place at the time defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The transportation policy required adequate training of personnel transporting residents, including safe wheelchair transportation, proper use of restraints, and procedures for what to do if someone falls. The CNA had completed annual abuse and neglect training and had acknowledged the transportation training checklist and passenger assistive techniques, which included always using seat belts and ensuring passenger restraints fit securely. Despite this training and policy framework, the CNA did not secure the resident with the lap belt, did not respond appropriately when the resident reported sliding, left the resident unattended in the van, failed to seek assistance after the fall, and transported the resident back to the facility while she remained on the floor of the van. These actions and inactions led to the substantiated neglect and the Immediate Jeopardy determination.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers regarding policy changes and performed competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee 3 times per week, including checks on arrival/departure to ensure residents are safely anchored and properly seated, quizzing drivers on who to call in the event of a fall, and speaking with residents about their trip.
- Monitor transportation compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Secure Wheelchair-Dependent Resident and Provide Supervision During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of the transportation van’s restraining seatbelt for a wheelchair-dependent resident during transport. The facility had a written Transportation Policy and Passenger Assistive Techniques procedure requiring that residents who use wheelchairs be safely secured with passenger restraints and that seat belts be used for all passengers. The CNA responsible for transport had completed the Transportation Training Checklist and acknowledged the transportation policy and passenger assistive procedures, which included guidance on safe wheelchair transportation, use of restraints, and what to do if someone falls. The resident involved was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, was dependent on a wheelchair for mobility, and required staff assistance with transfers using a lift. Despite this dependence on staff for safe mobility and transfers, the resident was transported in the facility van without the restraining lap belt being applied. During the return trip from a medical appointment, the resident reported to the CNA driver that she felt she was sliding down in her wheelchair. The CNA did not stop the van to reposition or secure the resident with the restraining seatbelt and continued driving until reaching her own personal residence. The CNA then left the resident unattended in the van while she went inside her residence. While unsupervised and not secured by a seatbelt, the resident slid out of the wheelchair onto the floor of the van. When the CNA returned, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. Instead, the CNA drove the resident back to the facility while the resident remained sitting on the floor of the van. Upon arrival, staff, including an LPN, observed the resident on the van floor and assisted with assessment and lifting the resident from the floor. The incident was determined by surveyors to constitute an Immediate Jeopardy situation on the date of occurrence.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers to communicate policy changes and perform competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee: checks upon arrival and departure 3 times per week to ensure residents are safely anchored in the van and properly seated; quiz transport drivers at each departure/arrival on who to call in the event of a fall; counsel on notifying nursing immediately in the event of a fall.
- Monitor compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Failure to Implement Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement a person-centered care plan for Resident #1 to maintain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident #1 was admitted on 08/08/2024 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and a history of falling. The quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment with daily decision making, and the quarterly fall risk assessment showed a score of 18, indicating high fall risk. The care plan for falls included an intervention dated 02/09/2026 to encourage use of a reacher and ensure the device was within reach. During observations on 03/17/2026, Resident #1 did not have a reacher plainly visible and was later observed without one. The resident stated she did not have the device and asked the surveyor to get her one. A CNA did not identify the reacher as a fall intervention, and an LPN also did not identify it as a fall intervention and reported being unaware that the reacher was part of the fall intervention. The DON was informed of the findings and confirmed there was no documentation to support that a reacher was in place per the plan of care.
Failure to Follow Weight Loss Management Policy After Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure a resident maintained acceptable nutritional status by not following its weight loss management policy after a significant weight loss was identified. Resident #2 was admitted with diagnoses including malignant neoplasm of the pylorus, dysphagia following cerebral infarction, and type 2 diabetes mellitus with chronic kidney disease. The resident’s record showed weights of 182.8 pounds on 01/05/2026 and 169.8 pounds on 02/03/2026 after a hospitalization for diabetic ketoacidosis and a gastrointestinal bleed, which reflected a 7.11% weight loss in one month. A nursing note documented that the resident returned from the hospital with a 13-pound weight loss and was eating 75-100% of meals, but there was no documentation that the dietitian, attending physician, or responsible party were notified within 24 hours, no IDT meeting within 72 hours, and no weekly weights or monthly IDT review as required by policy. The record also showed no dietitian assessment in February 2026 and no order for nutritional supplements or an appetite stimulant at that time. The resident’s care plan identified a possible nutritional deficit related to diabetes mellitus and non-compliance with diet, but there were no new interventions documented after the significant weight loss was identified. Later, the dietitian noted the resident had lost 13.6 pounds over two months and recommended sugar free health shakes with meals for weight maintenance, but observations on two separate days showed the resident did not receive the shakes with lunch. Staff confirmed the shakes were not on hand and had not been provided, and the DON confirmed the resident had not received any health shakes since the dietitian’s recommendation.
Medication Administration and Change-in-Condition Monitoring Deficiencies
Penalty
Summary
Nurses and nurse aides were not ensured to have the appropriate competencies to care for residents by failing to clarify the correct dosage for ordered Voltaren 1% external gel for two residents. One resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, GERD, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and a history of falling, and had a BIMS score of 7 indicating severe cognitive impairment. The resident had a physician order for Voltaren 1% gel to be applied to both hands twice daily for osteoarthritis, but the medication was administered without the dosage ordered by the physician. Another resident with diagnoses including CAD, heart failure, hypertension, GERD, renal insufficiency, and arthritis had a BIMS score of 11 indicating moderate cognitive impairment and also had a physician order for Voltaren 1% gel to be applied to both lower extremities twice daily for pain, but the medication was likewise administered without the dosage ordered by the physician. The facility also failed to notify the physician of changes in condition for a resident who had diagnoses including carotid artery stenosis, heart failure, hypertension, cardiomegaly, cerebral ischemia, stage 3 CKD, dysuria, lumbar compression fracture, history of falling, traumatic hemorrhage of the right cerebrum, dyspnea, nasal bone fracture, and anxiety, and whose MDS showed severely impaired cognitive skills for daily decision making. The care plan required monitoring and reporting edema, weight gain over 2 lbs a day, difficulty breathing, level of consciousness, and breath sounds. The record documented 4+ edema in the lower extremities, medication being held because the resident was incoherent, and wheezing and congestion treated with ipratropium-albuterol nebulizer solution, but there was no documentation that the physician was notified of the edema or level of consciousness, no documentation of a post-nebulizer assessment, and the resident was weighed weekly instead of daily as planned.
Residents Did Not Receive Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays. During a resident council interview, Resident #19 reported receiving mail Monday through Friday but not on Saturdays. The Office Manager stated she picked up the facility's mail and residents' mail from the post office Monday through Friday and distributed residents' mail after returning, but did not go to the post office on Saturdays. The Administrator confirmed that both the facility's mail and residents' mail were delivered to the provider's post office box, that the Office Manager had the key and collected mail Monday through Friday, and that the facility did not have a dedicated staff member to check the post office box on Saturdays. The Administrator confirmed residents were not able to receive mail on Saturdays.
Nebulizer Tubing Not Dated or Properly Stored
Penalty
Summary
The facility failed to provide respiratory care in accordance with its own policy for Resident #5, who was admitted with diagnoses including chronic systolic congestive heart failure, atherosclerotic heart disease, type 2 diabetes mellitus, ischemic cardiomyopathy, anxiety disorder, and a fracture of the neck of the right femur sequela. Current physician orders in March 2026 included ipratropium-albuterol inhalation solution every 6 hours for 3 days and albuterol sulfate inhalation solution every 6 hours as needed for wheezing or shortness of breath, and the EMAR documented that the resident received the ordered ipratropium-albuterol treatments. The facility policy stated that oxygen and nebulizer tubing would be changed twice per month on the 1st and 15th, dated at that time, and checked each shift to ensure the tubing remained in a designated bag and was labeled properly. However, observations of the resident’s room showed a nebulizer machine on the dresser beside the bed with the tubing and face mask connected to the side of the machine, not dated, and not properly stored in a plastic bag. A DON observed the same condition and confirmed that the nebulizer tubing should be dated and the tubing and face mask should be stored in a plastic bag when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. For Resident #5, who was admitted with diagnoses including type 2 diabetes mellitus, right hip pain, aftercare following right hip replacement surgery, presence of a right artificial hip joint, fracture sequela of the right femur neck, and chronic venous hypertension with ulcer and inflammation, the record showed physician orders for daily care of a right hip incision and wounds to the left great toe and right heel. The admission MDS indicated a BIMS score of 14 and that the resident had a surgical wound and unstageable wounds present on admission. During observation and interview, the resident stated she had a right hip wound with slight drainage and wounds on her left great toe and right heel, but there was no signage posted outside her room indicating Enhanced Barrier Precautions were in place. The DON confirmed the resident should have been on EBP and that a sign should have been posted. For Resident #14, the record showed diagnoses including traumatic brain injury, aphasia, post-traumatic seizures, hemiplegia, and gastrostomy status, and the quarterly MDS indicated severe impairment with daily decision making. The resident had a feeding tube, and the physician’s order for EBP required hand sanitizer on entry and exit and gown and gloves for high-contact care activities, including device care or use of the feeding tube. During observation, an LPN administered medications via PEG tube without donning a gown. The LPN was unable to confirm that a gown was required until after reviewing the order, and the DON was informed that EBP had not been implemented as ordered for this resident.
Failure to Obtain Consent and Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints imposed for discipline or convenience. Specifically, the facility did not obtain consent, secure a physician's order, or conduct appropriate assessments before using roll control bolsters on residents' beds. This deficiency was observed in four out of five residents reviewed for restraints, indicating a systemic issue in the facility's adherence to its own policies and regulatory requirements. Resident #20, who had severe cognitive impairment and was dependent on staff for mobility, was observed with bolsters on the bed without prior assessment, consent, or a physician's order. Similarly, Resident #24, with cognitive impairment and extensive assistance needs, was also found with bolsters without the necessary documentation and approvals. Both residents had care plans indicating a potential for falls, but the facility did not follow the required procedures for restraint use. Residents #11 and #29 were also subjected to the use of bolsters without documented assessments, consents, or physician's orders. Resident #11 had a history of falls and severe cognitive impairment, while Resident #29 had multiple diagnoses including dementia and was dependent on staff for daily living activities. Interviews with the facility's administrator confirmed these failures, highlighting a lack of compliance with the facility's policies and regulatory standards regarding restraint use.
Inadequate Fall Prevention Interventions for Resident
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards by not implementing appropriate interventions after each fall. The resident, who had a history of falls and several medical conditions including Alzheimer's disease, dementia, and a hip replacement, experienced multiple falls over a period of time. The medical record review revealed that the resident had severely impaired cognitive skills and was dependent on staff for daily activities. Despite this, the interventions documented after each fall were inadequate to prevent further incidents. The resident's falls were documented on three separate occasions, with the first incident occurring when the resident's feet got tangled in her walker, causing her to fall and hit her head. Subsequent falls included slipping in her own urine while attempting to go to the bathroom. The care plan interventions, such as reminding the resident to get her balance before moving and wearing well-fitted shoes, were confirmed by the Director of Nursing to be inappropriate for preventing falls in this resident. The facility's failure to implement effective fall prevention strategies contributed to the ongoing risk of falls for the resident.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment from bed rails prior to their installation. This deficiency was identified for three residents who were reviewed for accident hazards. The facility's policy requires an assessment of risks, including entrapment, and obtaining informed consent before installing bed rails. However, for residents with severe cognitive impairments and various medical conditions, such as chronic heart failure, dementia, and diabetes, there was no documentation of such assessments being conducted. Resident #15, who had severe cognitive skills for daily decision-making and required total assistance with activities of daily living, was observed with bed rails in place without prior risk assessment. Similarly, Resident #11, with a history of falls and severe cognitive impairment, and Resident #20, who was totally dependent on staff for mobility, also had bed rails installed without documented risk assessments. Interviews with the facility administrator confirmed the lack of assessments for these residents, indicating a failure to adhere to the facility's policy and procedures regarding bed rail installation.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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