Matthews Memorial Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alexandria, Louisiana.
- Location
- 5100 Jackson Street Ext., Alexandria, Louisiana 71303
- CMS Provider Number
- 195600
- Inspections on file
- 33
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Matthews Memorial Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure call lights were accessible and appropriate for several residents, including one with hemiplegia, aphasia, functional quadriplegia, and severe cognitive impairment who could not operate a standard call bell and did not have an adapted device in place. Observations on multiple occasions showed call lights wrapped around bed rails, wedged between the mattress and rail, lying on the floor at the foot of the bed, placed on top of a mini fridge, or hanging on the wall, all out of residents’ reach. Staff, including CNAs, LPNs, the DON, and a corporate RN, acknowledged that call lights were not within reach despite care plans identifying fall risk and specifying that call lights should be kept within reach.
Two residents with existing pressure ulcers and high risk for skin breakdown did not receive ordered pressure-relief interventions and scheduled repositioning. One resident with multiple comorbidities and a Stage 2 heel ulcer had a care plan and posted signage requiring heel protectors, yet surveyors repeatedly observed the resident in bed or in a specialized wheelchair with heels on the mattress and the heel protectors stored on top of a closet; a family member reported never seeing them applied, and nursing staff acknowledged they should have been in use. Another resident with paraplegia, bilateral above-knee amputations, and Stage 4 buttock ulcers was care planned for a q2h turn schedule with wedges, but was repeatedly observed lying on his back with no supportive equipment while the wedges remained unused in a box; the resident stated staff did not turn or offer to turn him, and the assigned CNA and DON later acknowledged that q2h turning should have been provided but was not.
The facility did not ensure timely physician notification for an antibiotic order following a consultant's recommendation for a resident with a tooth abscess, resulting in a delay of several days before treatment was initiated. Additionally, another resident with multiple stage 4 pressure ulcers did not receive wound care as ordered on several occasions, with gaps in documentation and responsibility among nursing staff.
A resident with severe malnutrition and quadriplegia fell while attempting to get up from bed, resulting in acute right pubic fractures. The facility failed to immediately inform the resident's representative and consult the physician, with the representative only learning of the fall during a visit. The responsible LPN was suspended for not notifying the representative promptly.
The facility failed to notify physicians of elevated blood sugar levels for two residents with diabetes, despite physician orders requiring such notifications. One resident had CBG levels exceeding 300 on multiple occasions, while another had levels over 400, with no documentation of physician notification. The Corporate RN confirmed the oversight.
Two residents in a LTC facility experienced inadequate pain management. One resident with Multiple Sclerosis did not receive prescribed Oxycodone despite reporting severe pain, while another resident with Type 2 Diabetes reported high pain levels without receiving any medication. Staff failed to administer pain relief or contact a physician, violating care standards.
The facility failed to ensure accurate reconciliation of controlled medications at each shift change. Despite the policy requiring a controlled drug count by both outgoing and incoming nurses, an LPN confirmed she did not reconcile narcotics with the off-going nurse. Another LPN also failed to reconcile medications with the incoming nurse. The DON confirmed the requirement for controlled substances to be counted at the beginning and end of each shift.
The facility failed to provide snacks and timely meals according to residents' needs and preferences. Observations and interviews revealed that snacks were not readily available, and residents had to request them from the nurse's station. Some residents did not receive meals in a timely manner, with one resident not receiving breakfast until late morning after being admitted the previous day. The facility's meal service times exceeded 14 hours from dinner to breakfast, and only residents with a doctor's order received snacks at specific times.
Two residents with cognitive impairments were not provided with necessary shaving services, as required by the facility's policy. One resident, dependent on staff for personal hygiene, was observed with facial hair, and the CNA Task Schedule showed inadequate documentation of care. Another resident, requiring substantial assistance, was also observed with facial hair and expressed that the usual caregiver was unavailable. The ADON confirmed both residents needed assistance with shaving, which they did not receive.
A facility failed to provide necessary treatment and services for a resident with stage 4 pressure ulcers, leading to inadequate wound assessments and care. The resident, who required assistance with mobility, did not receive consistent turning and repositioning as per their care plan. The facility lacked a wound care nurse, resulting in missing wound assessments and unawareness of the current status of the resident's wounds.
A facility failed to provide proper respiratory care for a resident with chronic respiratory failure. The resident's nebulizer mask and oxygen tubing were found uncovered and undated, contrary to professional standards. The DON confirmed that the equipment should be covered and changed every seven days.
A resident fell and sustained a femur fracture after being placed in a shower chair without a safety belt by a CNA. The facility's policy required safety belts on shower chairs, but this was not followed. Multiple CNAs were aware of the missing safety belts but did not report the issue, and the maintenance logs had no records of the problem. The resident required emergency surgery following the fall.
A resident experienced a fall and was not immediately assessed with no injury noted. The facility failed to promptly notify the physician and the resident's representative. Later, the resident was found to have swelling and bruising, and an X-ray revealed an acute fracture. This indicates a failure to follow the facility's policy on immediate notification.
A facility failed to promptly resolve a grievance filed by a resident's RP regarding delayed notification of a fall. The RP was informed of the fall a day later, and the grievance was not resolved within the required timeframe, contrary to the facility's policy.
Failure to Ensure Accessible and Appropriate Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and ensure call lights were accessible and appropriate for residents’ functional abilities. One resident with hemiplegia, aphasia, dysphagia, functional quadriplegia, and severe cognitive impairment was care planned as dependent for mobility and ADLs, with an intervention for the call bell to be within reach due to a history of falls and impaired mobility. Multiple observations on different days showed this resident in bed with the traditional call bell cord wrapped on the right side rail and the button positioned between the mattress and side rail, not within reach. When CNAs placed the call bell in the resident’s left hand and verbally prompted her to use it, she repeatedly shook the device and was unable to press the button to trigger assistance. The DON acknowledged the resident’s paralysis on one side, stated she believed the resident could use a padded/tap-activated call bell, and confirmed that the resident did not have a call bell in place that accommodated her functional needs at that time. Additional deficiencies were identified for four other residents whose call lights were not within reach despite care plans indicating they were at risk for falls with interventions including keeping the call light within reach. One resident, admitted with dementia, depression, psychosis, and other conditions, required assistance with toileting, bathing, dressing, and bed mobility; observations showed this resident asleep in bed with the call light lying on the floor at the foot of the bed on two occasions, not within reach. A CNA confirmed the call light was not within reach and explained that the distance from the wall unit to the head of the bed prevented proper placement without a clamp, and the DON confirmed the call light should have been within reach. Another resident with hemiplegia, aphasia, depression, anxiety, and dependence for transfers and toileting was observed lying in bed with the call light placed on top of a mini fridge at the foot of the bed on two separate observations; the resident stated he could not reach his call light and relied on his roommate to press it for assistance, and an LPN confirmed the call light was not within reach. Further observations showed a resident with diabetes, dementia with mood disturbance, heart failure, CKD, and mobility needs requiring a cane and assistance with ADLs sitting on the side of the bed while the call light was on the opposite side and not within reach. Two LPNs confirmed that this resident’s call light was not within reach and attributed the problem to the bed being too far from the call light. Another resident with seizures, CHF, CKD, generalized muscle weakness, debility, and an above-knee amputation, who required substantial to total assistance for transfers and toileting, was observed lying in bed with the call bell hanging on the wall and not within reach. An LPN confirmed this call bell was not within reach. The DON and a corporate RN later confirmed that each resident should have a call light within reach, but at the time of surveyor observations, these residents did not have accessible or appropriately adapted call systems as required by their assessed needs and care plans.
Failure to Implement Pressure-Relief Devices and Turning Program for Two Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure-relieving interventions and turning/repositioning necessary to promote healing of existing pressure ulcers and prevent further skin breakdown for two of three sampled residents. One resident, admitted with multiple comorbidities including squamous cell carcinoma of the skin, type 2 diabetes with neuropathy, peripheral arterial disease, and identified as at risk for pressure ulcers, had a documented Stage 2 pressure ulcer on the right heel. The resident’s care plan, initiated in late August 2024, included heel protectors as an intervention under a focus on safety devices and special equipment to maintain optimal functioning. Despite posted signage in the room stating the resident was to wear heel protectors, surveyor observations on multiple days and times showed the resident lying on her back in bed or sitting in a specialized wheelchair with her heels resting on the mattress and the heel protectors stored on top of the clothes closet rather than on her heels. Across several observations, the heel protectors remained unused on top of the closet while the resident’s heels were in direct contact with the mattress, and no positioning supports were in place. A family member reported never having seen the heel protectors applied to the resident. The treatment nurse confirmed the resident had a Stage 2 pressure ulcer on the right heel that had previously been a deep tissue injury and stated that pressure reduction was one of the interventions in place to promote wound healing. An LPN later confirmed that the resident’s heel protectors were on top of the closet instead of on the resident’s heels, and acknowledged that they should have been applied as part of the wound-healing interventions. The second resident involved had paraplegia, neuromuscular bladder dysfunction, bilateral above-the-knee amputations, and existing Stage 4 pressure ulcers on both buttocks, with documented wound measurements from a recent skin evaluation. This resident was dependent for bed mobility and transfers and was care planned for the facility’s turn and repositioning program, with a posted turn schedule indicating side-to-side repositioning every two hours. However, repeated observations over two days showed the resident in bed on his back with the head of the bed elevated, without any supportive positioning equipment in use, while two positioning wedges remained unused in a box in the corner of the room. The resident reported that staff did not turn or reposition him every two hours, that he did not refuse turning, and that no one had offered to reposition him that day. A CNA assigned to the resident stated she was familiar with his care needs but believed he was not on a turn schedule, admitted she had not turned or offered to turn him during her shift, and then acknowledged, upon review of the posted schedule, that she should have offered repositioning every two hours but did not. The DON also acknowledged the resident should have been turned or offered turning every two hours and was not.
Failure to Ensure Timely Physician Notification and Wound Care as Ordered
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with a history of gastro-esophageal reflux disease, hypertension, delusional disorder, and cellulitis, there was a delay in obtaining an antibiotic for a tooth abscess. After returning from a medical appointment with a recommendation for an antibiotic, the nurse contacted the resident's physician and left a message but did not follow up the next day. The oncoming nurse was not made aware of the situation, and the issue was not documented in the 24-hour report as required. The physician was not contacted again until several days later when the resident complained of pain and swelling, at which point an antibiotic was finally ordered. Another resident with quadriplegia, pain, hypertension, urinary tract infection, and multiple stage 4 pressure ulcers did not receive wound care as ordered on several documented dates. The treatment nurse, who worked weekdays, stated that floor nurses were responsible for treatments in her absence, and the RN supervisor was responsible on weekends. However, there was no documentation that wound care was provided on specific dates, and this was confirmed by the DON. The lack of timely follow-up and communication among staff led to missed treatments and a delay in physician notification for necessary care.
Failure to Notify Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately inform a resident's representative and consult the resident's physician following an accident involving the resident that resulted in injury and had the potential for requiring physician intervention. The incident involved a resident who was found on the floor after attempting to get up from bed, reporting no pain or head injury at the time. Despite the resident's fall, the facility did not notify the resident's representative immediately, and the representative only learned of the incident during a visit later that day. The resident, who had a history of severe protein-calorie malnutrition and functional quadriplegia, was admitted to the facility with previous pelvis fractures. After the fall, the resident's family requested an x-ray, which revealed acute right pubic fractures. The facility's failure to notify the resident's representative promptly was acknowledged by the Director of Nursing and Corporate Nurse, and the responsible LPN was suspended following the event.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two residents. Resident #27, who was admitted with Type 2 Diabetes Mellitus with Neuropathy and long-term use of insulin, had physician orders for insulin administration and capillary blood glucose (CBG) monitoring. The orders specified that the physician should be notified if CBG levels were less than 60 or greater than 300. However, the resident's CBG levels exceeded 300 on multiple occasions in September 2024, and there was no documentation that the physician was notified of these elevated levels. Similarly, Resident #64, who was admitted with Type 2 Diabetes Mellitus and other conditions, had physician orders for insulin administration and CBG monitoring. The orders required notification of the physician if CBG levels were greater than 400. Despite this, the resident's CBG levels exceeded 400 on several occasions in August and September 2024, and there was no documentation that the physician was informed. Interviews with the Corporate RN confirmed the lack of documentation and acknowledged that the physician should have been notified in both cases.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #4, who has a history of Multiple Sclerosis and Chronic Pain Syndrome, reported severe pain and did not receive her prescribed pain medication, Oxycodone, as needed. Despite calling for the nurse multiple times during the night, Resident #4 did not receive any pain relief, as confirmed by the CNA and the LPN on duty, who admitted to not attending to the resident throughout her shift. Resident #64, diagnosed with Type 2 Diabetes Mellitus and other conditions, consistently reported high pain levels without receiving any pain medication. The resident's MAR documented pain levels ranging from 6 to 7, yet no pain relief was administered. The LPN responsible for Resident #64 acknowledged the resident's pain but failed to contact the physician to address the lack of pain medication orders. The facility's policy on pain management emphasizes the importance of treating pain and revising care plans as necessary. However, both residents experienced unrelieved pain due to the staff's failure to administer medication or seek medical advice, resulting in a breach of professional standards and the residents' care plans.
Failure to Reconcile Controlled Medications at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate reconciliation of controlled medications for each resident. This deficiency occurred because the facility did not conduct a physical inventory of controlled medications at each shift change, as required by their policy. The policy, revised in November 2017, mandates that a controlled drug count be performed at the beginning of each shift by both the outgoing and incoming medication nurses. However, on September 8, 2024, an LPN who reported to work at 7:00 a.m. confirmed that she did not reconcile narcotics with the off-going nurse or any other nurse, despite acknowledging that she should have. Similarly, another LPN who worked the previous shift from 11:00 p.m. to 7:00 a.m. also confirmed that she did not reconcile medications with the incoming nurse. The Director of Nursing (DON) confirmed that all controlled substances should be counted at the beginning and end of each shift by both the on-coming and off-going nurses.
Failure to Provide Snacks and Timely Meals
Penalty
Summary
The facility failed to ensure that snacks were served at times in accordance with residents' needs, preferences, and requests. Observations and interviews revealed that snacks were not available at all times, and residents had to request them from the nurse's station. Residents reported that snacks were labeled with specific names, and those without a label did not receive any. Additionally, the facility did not provide snacks for residents outside of scheduled meal service times, and some residents reported not receiving meals in a timely manner. For instance, one resident did not receive breakfast until 11:30 a.m. after being admitted the previous day and had not eaten since the previous evening. Interviews with the Director of Nursing (DON) and the Dietary Manager revealed that only residents with a doctor's order received snacks at specific times, and bedtime snacks were left at the nurse's station. This practice excluded residents who could not go to the nurse's station to request a snack. The facility's meal service times were also noted to be longer than 14 hours from dinner to breakfast, which contributed to residents not receiving adequate nourishment. The Administrator and Dietary Manager acknowledged these issues, indicating awareness of the deficiencies in meal and snack distribution.
Failure to Provide Necessary Shaving Services for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to perform Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents were not provided with shaving services as required. Resident #2, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed with facial hair on multiple occasions, indicating a lack of shaving. The CNA Task Schedule for September 2024 showed no documentation of a bath for Resident #2, and personal hygiene was only recorded on two specific dates. Resident #82, who has moderate cognitive impairment and requires substantial assistance for bathing, was also observed with facial hair. The resident expressed that someone usually shaved him, but the person was not available. Both residents were confirmed by the Assistant Director of Nursing (ADON) to need assistance with shaving, which they did not receive. These observations and interviews highlight the facility's failure to adhere to its policy of providing necessary personal hygiene care, including shaving, for residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice, to promote healing and prevent infection. The resident, who was cognitively intact and required assistance with mobility, had multiple stage 4 pressure ulcers on the sacral region and buttocks. Despite having physician's orders for specific wound care treatments, the facility did not ensure that the resident's wounds were accurately assessed and documented on a weekly basis as required by their policy. The Director of Nursing (DON) confirmed that there were missing wound assessments for the resident's pressure ulcers over a specified period, and acknowledged that the assessments should have been conducted weekly by a nurse. Additionally, the facility failed to implement a consistent turning and repositioning program for the resident, which was part of the care plan to prevent further skin breakdown. During an observation, the resident reported that staff did not turn or reposition him every two hours as required, and that his positioning wedge was not in use. The DON was unaware of the current status of the resident's sacral wound and why treatment orders for a stage 4 pressure ulcer were still in place. The facility had not had a wound care nurse since June 2024, which contributed to the lack of proper wound assessments and care.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of hypertensive heart failure, gastrostomy status, and chronic respiratory failure with hypoxia. The resident's care plan indicated a risk for shortness of breath and required oxygen as ordered. During observations, the resident's nebulizer mask and oxygen tubing were found uncovered and undated, lying on the over-bed table and oxygen concentrator, respectively. Interviews confirmed that the oxygen equipment was not properly labeled or stored, and the Director of Nursing acknowledged that the equipment should be covered and changed out every seven days.
Failure to Secure Resident in Shower Chair Leads to Injury
Penalty
Summary
The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering, resulting in a fall and subsequent injury. On 04/19/2024, Resident #3, who required substantial assistance with bathing and transfers, was placed in a shower chair without a safety belt by S5 CNA. During the shower, Resident #3 fell from the chair to the floor, sustaining a displaced left intertrochanteric femur fracture, which required surgical intervention. The facility's policy mandated the use of safety belts on shower chairs, but this was not adhered to in this instance. Interviews with multiple CNAs revealed that the shower chairs had been without safety belts for an unspecified period, and the issue had not been reported to maintenance. S5 CNA admitted to using the shower chair without a safety belt on multiple occasions, assuming the issue had already been reported. Other CNAs confirmed the absence of safety belts on the shower chairs and acknowledged that they were aware of the requirement for safety belts but did not log the issue in the maintenance log. The maintenance supervisor confirmed that there were no records in the maintenance logs regarding the missing safety belts on the shower chairs. The administrator acknowledged that the shower chair used for Resident #3 did not have a safety belt and confirmed that all shower chairs should have safety belts attached for resident safety. This deficiency resulted in actual harm to Resident #3, who required emergency medical treatment and surgery following the fall.
Failure to Immediately Notify Physician and Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident's representative when a resident experienced a fall. On 04/05/2024, Resident #1 slid out of bed at approximately 9:12 p.m. and was assessed with no injury noted. The nurse's progress notes documented that the resident was assisted back to bed and instructed to use the call light, but there was no documentation that the resident's physician or representative had been notified of the fall. The incident report indicated that the physician was contacted at 9:15 p.m., but the time of contact for the resident's representative was not documented. Later, on the same day at 9:19 p.m., while assisting Resident #1 to undress, a CNA noted swelling and bruising on the resident's right upper arm, and the resident complained of pain in the right ribcage and back. The physician was notified, and an order for a stat X-ray was given. The resident's representative was also notified at this time. The X-ray results revealed an acute fracture of the right 6th rib. This sequence of events indicates a failure to promptly notify the physician and the resident's representative immediately after the initial fall, as required by the facility's policy.
Failure to Promptly Resolve Grievance Regarding Resident Fall Notification
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance filed by a resident's Responsible Party (RP). The grievance was related to the RP not being notified of a fall that the resident sustained. The facility's policy requires that grievances be resolved promptly and that findings and recommendations be discussed with the complainant within five workdays. However, the RP was not informed of the fall until the day after it occurred, and the grievance was not resolved within the required timeframe. The incident involved a resident who fell on the night of April 5, 2024. The RP was not notified of the fall until the following night, despite the facility's policy requiring immediate notification. The Director of Nursing (DON) registered the grievance electronically on April 8, 2024, but the complaint had not been completed by the time of the survey. Interviews with the involved staff confirmed the delay in notification and the failure to resolve the grievance promptly.
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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