Natchitoches Nursing And Rehabilitation Center, Ll
Inspection history, citations, penalties and survey trends for this long-term care facility in Natchitoches, Louisiana.
- Location
- 750 Keyser Avenue, Natchitoches, Louisiana 71457
- CMS Provider Number
- 195293
- Inspections on file
- 39
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Natchitoches Nursing And Rehabilitation Center, Ll during CMS and state inspections, most recent first.
The facility failed to provide ordered meals, supplements, and adequate feeding assistance to several cognitively intact but fully dependent residents. One resident with quadriplegia, malnutrition, and pressure ulcers reported often receiving only one meal per day, not being awakened or assisted for meals, and not consistently receiving prescribed supplements. Another resident with quadriplegia and severe protein-calorie malnutrition stated that staff did not always wake him for meals, that multiple meals were missed when he was sleeping, and that he felt rushed when being fed. A third resident with quadriplegia and diabetes reported relying on staff for feeding, sometimes not receiving her meal tray because it was left on the cart and returned to the kitchen, and on one occasion being told the kitchen was closed so she received nothing to eat. Staff interviews described problems with feeding during shift change, residents reporting missed meals, and communication failures that led to meal tickets not being printed for residents who had returned from the hospital.
A resident with quadriplegia, intact cognition, depression, low BMI, and a stage 4 sacral pressure ulcer required assistance with all ADLs but repeatedly did not have an accessible call light. Surveyors observed the call bell placed between the bed and side rail and later on a dresser, both out of the resident’s reach. The resident reported being unable to use the call system and sometimes relying on a roommate to call for help, and stated they would not have been able to summon assistance over a weekend if needed. A hospice RN noted that although the call bell was placed within reach during her visit, she did not believe the resident could effectively use it, and the administrator later confirmed the call bell was not within reach.
A resident with quadriplegia, intact cognition, and multiple comorbidities, fully dependent on staff for ADLs, reported repeated delays in receiving incontinent care despite a care plan requiring prompt call light response and q2h peri care. The resident stated that requests for assistance beginning in the early morning hours were not addressed for several hours and that staff sometimes turned off the call light without providing care. The resident filed multiple grievances about call bell response times, and an SSD, an LPN, a CNA, and the ombudsman all confirmed that the resident had complained of not being bathed and changed in a timely manner, demonstrating a failure to provide necessary ADL services and timely incontinent care.
Surveyors found that the facility failed to meet professional standards by not completing ordered monthly suprapubic catheter changes for a resident, and by not entering or following wound clinic orders for a Stage 3 gluteal pressure ulcer, resulting in the wound being observed open without a dressing. In addition, another resident with diabetic and chronic foot ulcers had physician wound care orders that were not followed, demonstrating multiple lapses in adherence to ordered catheter and wound treatments by nursing staff, including an LPN and the treatment RN.
Staff failed to maintain resident dignity during meals when several CNAs stood while feeding total-care residents who required full assistance with eating. One resident with quadriplegia and chronic pain, another with quadriplegia, multiple contractures, chronic pain, and visual impairment, and a third with dementia, generalized weakness, dysphagia, and coordination deficits were all observed being fed by standing CNAs. In interviews, the CNAs confirmed these residents were total care and dependent for meals, and the DON acknowledged that staff had been instructed not to stand while feeding residents.
A cognitively intact resident was unable to access money from a personal trust fund despite repeatedly requesting it from the Administrative Assistant/Office Manager. The resident sought reimbursement for wheelchair parts and other purchases made by family, and submitted receipts, which were forwarded to a regional financial consultant for approval. The Administrative Assistant/Office Manager acknowledged that reimbursement checks were not issued within the required 3-day timeframe after receipt submission, resulting in a delay in the resident’s access to his own funds.
A resident with intact cognition and multiple conditions, including neuromuscular bladder dysfunction and a suprapubic catheter, did not have the catheter addressed in the comprehensive person-centered care plan, despite physician orders for catheter placement, routine care each shift, and scheduled changes. The facility's policy required care plans to identify resident problems and needs and to be reviewed at least quarterly, yet the care plan contained no documentation related to the suprapubic catheter. The resident was observed in a wheelchair with the suprapubic catheter hanging from the wheelchair arm, and the care plan coordinator confirmed that the catheter had not been included in the care plan as required.
A resident with diabetes, cellulitis, venous insufficiency, and multiple lower extremity ulcers had physician orders and a care plan for daily wound care and monitoring of infected wounds. Surveyors observed an RN performing wound care with a clean field prepared, but using soiled gloves to handle scissors from the clean field, failing to perform hand hygiene between glove changes, and using the same pair of gloves to cleanse and dress three separate purulent wounds while repeatedly accessing clean supplies. The resident was also observed with a soiled dressing with yellow drainage on one leg and exposed wounds with copious slough on the other leg and foot. The RN later acknowledged not following hand hygiene and glove-change practices, and the DON confirmed these findings.
A resident with a history of dementia and hip issues experienced a fall and was in significant pain, prompting a STAT x-ray order. Although the x-ray revealed a nondisplaced intertrochanteric fracture and results were available the same evening, nursing staff did not follow up or review the results until the next morning, resulting in a delay in care. Both LPNs involved acknowledged the lapse in timely follow-up, and the DON confirmed that standard protocol was not followed.
The facility failed to monitor and address the nutritional needs of two residents, leading to significant deficiencies. One resident experienced severe weight loss due to inadequate meal intake documentation and lack of assistance, while another was not provided a meal tray during lunchtime. Staff interviews revealed lapses in communication and adherence to care protocols, contributing to these deficiencies.
The facility failed to include the Infection Preventionist (IP) in its Quality Assessment and Assurance (QAA) committee meetings, as required by policy. Despite having various staff members present, the IP's absence was confirmed by the Administrator, highlighting a significant oversight in infection control and prevention efforts for the facility's 58 residents.
A facility failed to notify a physician about a resident's 3+ edema, as required by physician orders. Despite multiple instances of 3+ edema documented over several months, the physician was not informed. An LPN confirmed the oversight, and the DON acknowledged the failure to meet professional standards of care.
A resident with cognitive intactness and multiple health conditions required assistance with ADLs, including nail care. Despite a care plan intervention to trim nails, observations revealed long, dirty nails, and the resident expressed a desire for them to be cut. The DON confirmed the need for nail trimming, indicating a lapse in care.
A facility failed to develop a comprehensive person-centered care plan for a resident with schizophrenia, diabetes mellitus, and chronic pain syndrome, who was involved in active discharge planning. Despite the resident's expressed desire to move to another facility, the care plan lacked discharge planning. Interviews confirmed the oversight, with the MDS coordinator attributing it to the care plan being completed before her employment, and the Administrator acknowledging the deficiency.
The facility failed to provide an ongoing activities program that supports residents' choices, particularly on weekends. Three residents reported a lack of organized activities, with one resident noting that bingo was the only activity offered during the week. Staff interviews confirmed the absence of weekend activities, and the Activity Director's time card showed no logged hours on the days in question. This deficiency affected the residents' ability to engage in meaningful activities as outlined in their care plans.
A hospice resident with Alzheimer's and other conditions experienced an accident resulting in injury and unrelieved pain. Despite the facility's policy requiring notification of the physician for abnormal pain, the Medical Director was not informed. The resident was found on the floor with a potential injury, but the facility delayed sending her to the ER, waiting for hospice assessment. Pain relief was ineffective, and the resident remained in severe pain until she was eventually sent to the ER the next day.
A resident with Alzheimer's and under hospice care experienced a fall and reported pain. Despite orders for Hydromorphone and Lorazepam every four hours, the resident did not receive these medications as prescribed, resulting in a nearly 12-hour gap in pain management. The resident was eventually sent to the ER for further evaluation and pain control.
The facility failed to maintain resident privacy during showering by leaving the shower room door open, contrary to policy. This affected two residents, one of whom expressed a preference for the door to be closed. Staff confirmed the door should have been closed, highlighting a breach of residents' rights to privacy and dignity.
A resident with severe cognitive impairment and a urinary tract infection did not receive the prescribed antibiotic, Augmentin, as ordered by the physician. The medication was not administered over several days, and there were no documented refusals. This failure was confirmed by the DON and a Corporate RN, highlighting a lapse in following the facility's medication administration policy.
The facility failed to properly dispose of garbage and refuse, as a dumpster outside the kitchen was found with its sliding door open, allowing a cat to jump out. Trash was on the ground, and a torn mattress and two walkers were outside the dumpster area. Despite signage to keep the door closed, it remained open. The Housekeeping Supervisor confirmed the area should be clean and the door closed, which was not adhered to.
The facility failed to ensure a safe and comfortable environment by not repairing a toilet base in a resident's room and a shower room door on X Hall. A resident reported the toilet had been in disrepair since moving in last year, and maintenance confirmed the issues. Observations revealed broken material under the toilet and a hole in the shower door.
A facility failed to ensure residents received care according to professional standards and care plans, affecting six residents. Critical lab results were not communicated to physicians, and ordered lab tests were not obtained. One resident with a history of Coumadin toxicity was hospitalized due to continued administration of Coumadin despite critical lab results. Other residents experienced missed medication doses and incomplete lab monitoring, highlighting deficiencies in adherence to physician orders and monitoring protocols.
The facility failed to effectively manage lab monitoring and communication, impacting several residents. A resident with a history of Coumadin toxicity was not properly monitored, leading to an Immediate Jeopardy situation. Other residents experienced missed lab draws and medication administration errors, highlighting systemic issues in the facility's resource management.
The facility failed to provide a private space for Resident Council Meetings, holding them in an open area near the entrance and nurses' station, compromising privacy. Additionally, the facility did not promptly address ongoing grievances from residents about staff not rounding, call lights not being answered, beds not being made, and loud CNAs at night. These issues persisted over several months, with the facility's response limited to monthly staff in-service training.
A resident with diabetes was not provided with an artificial sugar sweetener, Sweet'n Low, as part of their dietary needs. The resident reported not having access to the sweetener for several days, affecting their meal consumption. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners, and the administrator acknowledged the failure to ensure availability for residents on diabetic precaution diets.
A resident with moderate cognitive impairment and a history of wandering eloped from a facility due to inadequate supervision. The resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, and left unnoticed. The nurse, unaware of the resident's elopement risk, did not notify other staff or increase supervision. The resident was later found 0.4 miles away by staff from his Intensive Outpatient Program.
A resident at risk for elopement exited the facility unattended after an agency nurse unlocked the front door without notifying other staff. The resident, who was moderately cognitively impaired, was found 0.4 miles away on a busy roadway. The facility lacked effective supervision and communication systems, and there was no policy to train all staff on managing elopement risks.
Failure to Provide Ordered Meals, Supplements, and Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide nourishing, palatable, well-balanced diets and supplements as ordered and to ensure necessary feeding assistance for three dependent residents. Facility policy stated that clients are to be served their diets as ordered, and care plans and MDS assessments documented that these residents were cognitively intact but dependent on staff for all activities of daily living, including feeding. For one resident with quadriplegia, chronic kidney disease, neuromuscular dysfunction, pressure ulcers, anorexia, malnutrition, and an inability to feed himself, the care plan directed staff to feed all meals and give supplements as prescribed. This resident reported usually only getting to eat one meal a day, that staff sometimes did not come to feed him, and that if he was asleep staff would not wake him to feed him. He also stated he did not receive his ordered supplements very often or every day and denied refusing them. Another resident with quadriplegia, severe protein-calorie malnutrition (on hospice), low BMI, depression, and a stage 4 sacral pressure ulcer was also documented as cognitively intact and dependent on staff for all ADLs. His care plan included providing and serving diet as ordered. He reported that he sleeps a lot and that staff did not always wake him to feed him if he was asleep. He further stated that two of six meals over a weekend were missed because he was sleeping and no one returned to feed him, and that when he was fed he felt rushed, which caused him to feel full too quickly. A third resident with type 2 diabetes mellitus, quadriplegia, hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, also cognitively intact and fully dependent on staff, reported relying on staff for feeding and usually being fed only after all trays were passed on the hall. She stated there were two occasions in recent weeks when she did not receive her meal tray because it remained on the cart and was returned to the kitchen. On one of those occasions, after she asked a CNA and an agency nurse to retrieve the tray, they told her the kitchen was already shut down and being cleaned, so she did not receive anything to eat. Staff interviews corroborated systemic issues: a CNA reported problems with residents being fed at dinner due to meal carts arriving during shift change, an LPN reported residents (including the first two residents) complaining they had not been fed or had not eaten, and the dietary manager described communication failures about residents leaving and returning to the facility, resulting in meal tickets not being printed and residents not receiving trays, without these issues being reported to the Administrator.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring an appropriate and accessible call light system. The resident was admitted with major depressive disorder, quadriplegia, low BMI, depression, and a stage 4 sacral pressure ulcer, and had a BIMS score of 13 indicating intact cognition. The resident had impairments on both sides and required assistance with all ADLs. During an observation, the resident was seen lying in bed with the call bell positioned between the bed and side rail, out of reach. The resident reported being unable to use the call bell system and stated that at times he had to ask his roommate to call for help. Further observations showed that on another day the resident was again lying in bed with the call bell placed on a two-drawer dresser, out of reach. The resident stated that he would not have been able to call for help over the weekend if needed. The hospice RN reported that during her visit the call bell had been within reach but she did not think the resident could use it. In a subsequent interview, the administrator confirmed that the call bell was not within reach and the resident reported difficulty using the current call bell system due to mobility issues when it was not appropriately placed at all times.
Failure to Provide Timely Incontinent and ADL Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living, specifically incontinent care, to a resident who was fully dependent on staff. The resident had multiple diagnoses including Type 2 Diabetes Mellitus, quadriplegia, essential hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, and had an admission MDS BIMS score of 15 indicating intact cognition. Her care plan, reviewed on 03/04/2026, identified an ADL self-care performance deficit related to impaired mobility and included interventions such as responding to call lights promptly and providing perineal care every two hours and as needed. Despite these documented interventions, the resident reported that staff did not respond to her call bell in a timely manner for incontinent care. The resident stated that she began requesting incontinent care assistance at 2:30 a.m. and was not changed until between 7:00 a.m. and 7:30 a.m., and that staff sometimes entered her room, turned off the call light, and left without providing care. She reported using an Alexa device to track the time and stated she had notified several staff members, including the administrator, about these delays. The Social Services Director confirmed that the resident had filed three grievances in the last three months, two of which involved call bell response times related to incontinent care. An LPN and a CNA both reported that the resident had informed them she was not being cared for in a timely manner, and the ombudsman also reported that the resident had complained of not being bathed and changed in a timely manner. These observations and interviews demonstrated that the facility did not follow its own policy and care plan interventions to ensure timely ADL and incontinent care for this resident.
Failure to Follow Physician Orders for Catheter and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards of quality for residents with suprapubic catheter and wound care needs. One resident with multiple diagnoses including Type 2 diabetes, UTIs, cellulitis of both lower limbs, venous insufficiency, neuromuscular bladder dysfunction, and bowel and bladder incontinence had a physician order dated 09/15/2025 for a suprapubic catheter change every month and PRN for leakage/occlusion, with the GU bag to be changed on the 15th of each month. Review of the November and December Treatment Administration Records (TARs) showed that the scheduled suprapubic catheter changes on 11/15/2025 and 12/15/2025 were not documented as completed, and there was no documentation or progress note explaining why the catheter was not changed. The LPN responsible for treatments and the Unit Manager both confirmed, after reviewing the TARs, that the catheter had not been changed in those months despite the standing order and the facility expectation that missed treatments be documented with a reason. The same resident was also followed by an external wound care clinic for a left posterior gluteal pressure ulcer. A wound care clinic physician note dated 01/02/2026 documented an open Stage 3 pressure ulcer on the left posterior gluteus, with orders to cleanse with normal saline once daily, apply a topical antibiotic compound once daily when available, and cover with a 6x6 border gauze dressing once daily. Review of the resident’s January 2026 physician orders and TAR revealed no orders entered for treatment of this left posterior gluteal pressure ulcer and no documentation that the ordered wound care was performed. During interview, the treatment RN stated that she receives and inputs wound care clinic orders into the computer and adds them to the facility’s orders and TAR, and that the resident never refuses wound care. However, observation on 01/14/2026 showed the resident had an open wound on the left posterior gluteus with no dressing or bandage in place, and the treatment RN confirmed there were no other treatment orders for this wound beyond application of Calazinc cream to the buttocks and groin. Another resident with diagnoses including Type 2 diabetes with skin ulcer, non-pressure chronic ulcer of the right heel and midfoot, CKD stage 3A, Charcot joint of the left ankle and foot, depression, and an unspecified open wound of the left foot had physician orders for wound care that included cleansing with normal saline, applying ointment to the wound bed, covering with sterile gauze, and wrapping with Kerlix secured with tape. The report identifies this as an additional instance where physician wound care orders were not followed, contributing to the overall finding that the facility failed to provide care and services in accordance with professional standards of quality for wound and catheter management for sampled residents.
Staff Standing While Feeding Total-Care Residents During Meals
Penalty
Summary
Staff failed to honor residents' rights to a dignified existence and self-determination during meal service by standing while feeding multiple dependent residents. Resident #8, admitted on 10/12/2022 with diagnoses including other muscle spasm, complete C5-C7 quadriplegia, and other chronic pain, was observed on 01/12/2026 at 12:39 p.m. being fed by S7 CNA, who was standing during the meal. In a subsequent interview, S7 CNA stated that Resident #8 was total care and required assistance with meals. Resident #9, admitted on 11/19/2025 with multiple contractures, quadriplegia, other muscle spasm, chronic pain syndrome, age-related nuclear cataract, myopia, and primary generalized osteoarthritis, was observed on 01/12/2026 at 12:44 p.m. being fed by S8 CNA, who was standing, and again on 01/13/2026 at 12:26 p.m. being fed by S10 CNA, who was also standing. Both CNAs reported that this resident was total care and required assistance with meals. Resident #10, admitted on 12/26/2025 with unspecified dementia, generalized muscle weakness, lack of coordination, other symbolic dysfunctions, dysphagia, and idiopathic normal pressure hydrocephalus, was observed on 01/13/2026 at 12:25 p.m. being fed by S9 CNA, who was standing. S9 CNA stated that this resident was total care and required meal assistance. The DON (S2) confirmed that all staff were aware they were not to stand while feeding residents and that these CNAs should not have been standing to feed residents.
Failure to Provide Timely Access to Resident Trust Fund Reimbursement
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to manage his own financial affairs by not providing timely access to his personal funds. A quarterly MDS with an ARD of 11/24/2025 documented that Resident #4 had a BIMS score of 15, indicating he was cognitively intact. During an interview on 01/13/2026 at 9:25 a.m., the resident reported he had been unable to obtain money from his trust fund despite requesting it from the Administrative Assistant/Office Manager since 10/28/2025 and being repeatedly told he would receive it “tomorrow.” The Administrative Assistant/Office Manager stated the resident wanted money from his trust fund to reimburse his family for wheelchair parts and other purchases made in October 2025, and that he submitted receipts for these items on 12/02/2025, which she then emailed to the regional financial consultant for approval. In a subsequent interview, she confirmed she did not provide the reimbursement checks to the resident within 3 days after he submitted his receipts, and acknowledged that she should have done so. This sequence of events shows that despite the resident’s intact cognition and repeated requests, the facility did not ensure timely disbursement of the resident’s trust fund money following submission of receipts, resulting in a delay in his access to his own funds.
Failure to Develop Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing a resident's suprapubic indwelling catheter. The facility's policy required each resident to have a person-centered care plan identifying problems, needs, strengths, preferences, goals, and how the interdisciplinary team would provide care, with review and revision at least quarterly and with MDS assessments. Resident #7 was admitted with multiple diagnoses including Type 2 diabetes mellitus with diabetic mononeuropathy, UTI, anxiety, cellulitis of both lower limbs, edema, venous insufficiency, and neuromuscular dysfunction of the bladder. The resident had intact cognition, as evidenced by a BIMS score of 14 on the quarterly MDS. Physician orders included a urology consult for suprapubic catheter placement, suprapubic catheter care with soap and water every shift, and monthly suprapubic catheter changes with PRN changes for leakage or occlusion. Despite these orders and the presence of the suprapubic catheter, review of the resident's care plan showed no documentation or evidence that the catheter was addressed in the care plan. During observation, the resident was seen sitting in a wheelchair in the hallway with the suprapubic indwelling catheter hanging on the right wheelchair arm with a privacy cover. In an interview, the care plan coordinator, who was responsible for developing and updating all resident care plans and stated she reviewed and revised care plans quarterly and with changes in condition, confirmed that the care plan for this resident did not address the suprapubic catheter but acknowledged that it should have been included.
Failure to Follow Standard Precautions During Multi-Site Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and standard precautions during wound care for a resident with multiple lower extremity wounds. The facility’s policy on Standard Precautions required hand hygiene and appropriate use of personal protective equipment (PPE), including gloves and gowns, as the primary strategy to prevent healthcare-associated infections. The resident’s medical record showed multiple diagnoses including Type 2 diabetes with diabetic mononeuropathy, cellulitis of both lower limbs, edema, chronic venous insufficiency, and neuromuscular bladder dysfunction. The resident’s MDS indicated intact cognition, partial/moderate assistance with hygiene, and an infection of the foot with purulent drainage. The care plan documented actual skin integrity impairment with arterial and venous ulcers and directed staff to treat ulcers as indicated, keep skin clean and dry, and monitor and document wound status and signs of infection. Prior to the observed wound care, the resident was seen sitting in a wheelchair in the hallway with a suprapubic indwelling catheter bag hanging on the wheelchair arm and covered for privacy. A soiled dressing with yellow drainage was observed on the right leg, and the left lower leg and left foot had no dressings in place, leaving wounds exposed with copious slough in the wound bed. Physician orders for the resident included daily and PRN wound care to multiple sites on both lower extremities and toes, specifying cleansing with normal saline, application of an antibiotic compound, and coverage with ABD pads and Kerlix wraps secured with tape. During the observed wound care, the treatment RN prepared a clean field on the bedside table with normal saline, ABD pads, gauze, scissors, and a bottle of antibiotic compound, and donned a gown and clean gloves. She removed the old dressing from the right lower anterior leg wound and then removed dressings from the left lower leg and left foot, using the same soiled gloves to pick up scissors from the clean field to cut remaining bandages and then placing the scissors on the resident’s bed. After exposing wounds with copious yellow purulent drainage, she removed her gloves and donned a new pair without performing hand hygiene. She cleansed and dressed the right anterior wound, then, without changing gloves, handled clean supplies on the bedside table and cleansed and treated three separate wounds on the left lower leg and left toe, using the same gloves throughout. The RN did not change soiled gloves between wounds and continued to reach into the clean supply area. After completing wound care, she removed her gown and gloves and walked away to discard supplies. In interviews, the treatment RN acknowledged she failed to sanitize or wash her hands between glove changes and that she used the same soiled gloves to clean three separate wounds without changing them, and the DON confirmed these findings.
Failure to Timely Follow Up on STAT X-ray Results
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring timely follow-up on STAT x-ray results for a resident with a history of Alzheimer's Disease, dementia, left hip pain, and previous fractures. After an unwitnessed fall, the resident complained of left hip pain, prompting a nurse practitioner to order a STAT x-ray. The x-ray was performed, and the results, which showed a nondisplaced intertrochanteric fracture, were electronically signed and available the same evening. However, the results were not reviewed or acted upon until the following morning. Nursing staff on the evening and overnight shifts were aware that the x-ray results were pending but did not follow up with the imaging center or check for the results within the expected timeframe. The LPN on the night shift acknowledged that she did not call to check on the results, despite knowing that STAT results are typically received within a few hours. The Director of Nursing Services confirmed that the nurse assigned to the resident should have followed up on the x-ray results that night. As a result, there was a delay in identifying and responding to the resident's fracture.
Nutritional Care Deficiencies for Two Residents
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to significant deficiencies in their care. Resident #3, who has dementia and Alzheimer's disease, experienced a severe weight loss of 7.7% over a three-month period. The facility did not consistently record meal intake for Resident #3, failed to assist with all meals as care planned, and did not notify the MD/NP when the resident refused to eat or exhibited severe weight loss. Interviews revealed that the CNAs did not document meal intake in the medical record or report it to the nurse, and the dietary staff discarded meal tickets without recording intake information. Resident #36, who has multiple diagnoses including Type 2 Diabetes Mellitus and morbid obesity, was not provided a meal tray during lunchtime. The resident was observed sitting alone without a lunch tray while other residents were served. The CNA responsible for Resident #36's meal service mistakenly believed the resident had refused the meal and discarded the lunch tray without offering an alternative. Interviews with staff confirmed that Resident #36 typically eats in the day area and does not refuse meals, indicating a failure in communication and adherence to care protocols. The facility's policies on meal time observation and food acceptance were not followed, resulting in harm to Resident #3 and a failure to provide adequate nutrition to Resident #36. The Director of Nursing acknowledged the lapses in documentation and communication, which contributed to the deficiencies in care. The Registered Dietician's recommendations and weight records were not effectively communicated to the medical staff, delaying necessary interventions for Resident #3's weight loss.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee meetings included the required staff members, specifically the Infection Preventionist (IP), for the facility's quarterly meetings. The facility's policy, revised in October 2022, mandates that the QAA committee should include the Director of Nursing Services (DNS), Medical Director or designee, and three other staff members, one of whom must be in a leadership role, and the IP. However, a review of the facility's QAA Committee list and sign-in sheets for meetings held in 2024 and 2025 revealed that the IP was not present at any of the quarterly meetings. The absence of the IP from these meetings was confirmed during an interview with the facility's Administrator. The QAA Committee meetings were attended by various staff members, including the Executive Director, Director of Rehab, Activities Director, Dietary Manager, Housekeeping, Unit Manager-LPN, LPN-MDS, Medical Records, and Medical Director, among others. Despite the presence of these members, the lack of the IP's attendance was a significant oversight, as the IP plays a crucial role in infection control and prevention, which is vital for the health and safety of all 58 residents in the facility.
Failure to Notify Physician of Resident's 3+ Edema
Penalty
Summary
The facility failed to meet professional standards of quality by not notifying the physician of a resident's 3+ edema, as required by the physician's orders. The resident, who was admitted with a diagnosis of edema, had physician orders to monitor edema every shift and notify the physician if the edema reached 3+ or 4+. Despite this, the resident's medical records showed multiple instances of 3+ edema documented over several months, from January to March, without any notification to the physician. Interviews and observations confirmed the oversight. An LPN admitted to documenting 3+ edema on two consecutive days in March but did not notify the physician, as required. The Director of Nursing also confirmed that the physician was not notified of the resident's 3+ edema on these dates, acknowledging that the notification should have occurred. This failure to notify the physician of significant changes in the resident's condition represents a deficiency in the facility's adherence to professional standards of care.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living independently. Resident #59, who was admitted with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, and hypertension, was cognitively intact with a BIMS score of 15. The resident required partial to moderate assistance with various movements and had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and stroke. The care plan included interventions such as checking and trimming nails on bath day and as necessary. Despite these interventions, observations on two consecutive days revealed that Resident #59 had long, dirty fingernails, and the resident expressed a desire to have them cut. The resident stated that no one had offered to cut the nails, and he had never refused such care. The Director of Nursing confirmed the need for nail trimming and indicated that the Treatment Nurse should have performed this task, highlighting a lapse in the facility's adherence to the care plan for maintaining the resident's personal hygiene.
Failure to Develop Comprehensive Care Plan for Discharge Planning
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident #23, who was admitted with diagnoses including schizophrenia, diabetes mellitus, and chronic pain syndrome. Despite having a BIMS score indicating intact cognition and being involved in active discharge planning, the resident's care plan lacked any evidence of discharge planning. The facility's policy requires each resident to have a person-centered care plan that includes discharge planning, but this was not adhered to in the case of Resident #23. Interviews revealed that the resident had expressed a desire to move to another facility and had communicated this to the Director of Nursing and the Administrator, but had not received any feedback. The MDS coordinator confirmed that the resident was not care planned for either remaining in the facility long-term or for discharge planning, attributing the oversight to the care plan being completed by someone else before her employment. The Administrator acknowledged that the resident should have been care planned for discharge planning, which was not done.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program that supports residents' choices based on comprehensive assessments, care plans, and preferences. This deficiency was identified for three residents out of a sample of 24, with the potential to affect all 58 residents in the facility. The facility's policy requires daily activities, including weekends and holidays, but the activities calendar and interviews revealed a lack of activities on weekends. Specifically, on the weekend of March 8th and 9th, 2025, scheduled activities did not occur, and residents reported a lack of organized activities. Resident #41, with diagnoses including cerebral infarction and diabetes, expressed dissatisfaction with the facility's activities, noting that bingo was the only organized activity and that no activities occurred on the weekend in question. The resident's care plan emphasized the importance of group activities and personal preferences, which were not met. Interviews with staff confirmed the absence of activities on weekends, and the Activity Director's time card showed no logged hours on the days in question, indicating she was not present to conduct activities. Resident #25, with conditions such as paraplegia and major depressive disorder, also reported that no activities were offered on weekends since admission. Similarly, Resident #23, diagnosed with schizophrenia and chronic pain syndrome, stated that the facility lacked weekend activities and had insufficient activities during the week. The resident's care plan highlighted the need for activities that empower and engage the resident, which were not provided. The facility's failure to adhere to its policy and provide adequate activities led to this deficiency.
Failure to Notify Medical Director and Delay in Emergency Care for Hospice Resident
Penalty
Summary
The facility failed to notify the Medical Director when a hospice resident experienced an accident resulting in injury and unrelieved pain. The incident involved a resident with Alzheimer's Disease, Major Depressive Disorder, and other conditions, who was under hospice care. The resident was found on the floor with a raised area on her left knee, indicating potential injury. Despite the presence of aides and the resident's daughter, the facility did not immediately send the resident to the emergency room but instead waited for hospice to assess the situation. The facility's policy required notification of the physician or responsible party in cases of abnormal pain complaints or ineffective pain relief. However, the hospice nurse advised against sending the resident to the ER, suggesting that the absence of immediate bruising indicated no fracture. The resident was given Lorazepam and Hydromorphone for pain, but these medications did not alleviate her discomfort. The hospice nurse was unable to visit promptly, and the facility delayed further action until the following day, resulting in prolonged pain for the resident. Interviews with staff and the resident's responsible party revealed that the resident was in severe pain throughout the night and into the next day. The facility's Director of Nursing acknowledged that further action should have been taken when hospice did not arrive as expected. The resident was eventually sent to the ER, where her hip was repositioned, and an immobilizer was applied to her broken leg. The failure to notify the Medical Director and the delay in sending the resident to the ER contributed to the deficiency identified in the report.
Inadequate Pain Management for Resident Post-Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who required such services, as per professional standards and the resident's comprehensive care plan. The resident, who had a history of Alzheimer's Disease, Major Depressive Disorder, and was under hospice care, experienced a fall and reported pain. Despite having orders for Hydromorphone and Lorazepam to be administered every four hours for pain management, the resident did not receive these medications as prescribed. On the night of the incident, a nurse found the resident on the floor, displaying signs of pain with a swollen knee. The nurse contacted the hospice nurse, who advised administering the existing pain medications and scheduling an x-ray for the following morning. The resident received the medications approximately 20-30 minutes after the fall, which were effective in allowing the resident to sleep. However, the resident did not receive any further pain medication for nearly 12 hours, despite the order for administration every four hours. The following morning, another nurse assessed the resident's pain as significant, based on facial expressions, but delayed administering additional pain medication due to the previous nurse's report. The resident's daughter was consulted but declined further medication at that time. The resident was eventually sent to the ER for further evaluation and pain management. The facility's Director of Nursing acknowledged the lapse in administering pain medication as ordered.
Failure to Maintain Resident Privacy During Showering
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not maintaining privacy during showering. Observations on two separate occasions revealed that the shower room door was propped open while residents were receiving care, allowing staff, residents, and visitors to pass by and potentially see inside. This was contrary to the facility's policy, which required the door to be closed for warmth and privacy during resident care. Interviews with staff confirmed that the door should have been closed, but it was not. Two residents were directly affected by this deficiency. One resident, who had intact cognition, expressed a preference for the door to be closed while showering, indicating a lack of respect for his personal preferences and dignity. The other resident had moderately impaired cognition, which may have affected his ability to advocate for his privacy needs. The facility's failure to adhere to its own policies and procedures resulted in a breach of the residents' rights to privacy and dignity.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not implementing a physician's order for a resident. Specifically, the facility did not administer the prescribed antibiotic, Augmentin, to a resident who was diagnosed with a urinary tract infection, among other conditions. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was supposed to receive the medication starting on October 18, 2024, as per the physician's order. Upon review of the resident's Medication Administration Record (MAR), it was found that the antibiotic was not administered from October 18 to October 23, 2024, and there were no documented refusals of the medication. This oversight was confirmed during an interview with the Director of Nursing and a Corporate Registered Nurse, who acknowledged that the medication should have been administered as ordered. The facility's policy on medication administration emphasizes the responsibility of licensed nursing personnel to administer medications according to physician's orders, which was not adhered to in this case.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The facility's policy on garbage and rubbish disposal requires that all outside dumpsters be maintained in a clean and sanitary condition, with storage areas kept clean to discourage pests and outdoor trash receptacles kept covered. However, during an observation of the area outside the facility's kitchen, a blue dumpster was found with its sliding door left open, allowing a cat to jump out. Trash was observed on the ground in front of the dumpster, and a torn mattress and two walkers were found outside the dumpster area. Despite signage instructing that the dumpster door be closed at all times, the door remained open during a subsequent observation. An interview with the Housekeeping Supervisor confirmed that housekeeping was responsible for maintaining the cleanliness of the area and acknowledged that the sliding door should be closed and the area free of litter, which was not the case.
Facility Fails to Repair Toilet and Shower Door
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its residents, as evidenced by two specific deficiencies. Firstly, the toilet base in Room A was found to be in disrepair, with broken pieces of solid material observed underneath the toilet on two separate occasions. A resident occupying Room A reported that the toilet had been in disrepair since moving into the room the previous year. The resident's Quarterly MDS indicated a BIMS score of 15, suggesting intact cognitive function. Secondly, the shower room door on X Hall was observed to have a hole approximately 6 inches in width near the bottom. The maintenance staff confirmed the presence of the hole and acknowledged that the toilet base in Room A had rebroke, necessitating repair. These observations and interviews highlight the facility's failure to address and repair these issues in a timely manner.
Deficiencies in Lab Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person-centered care plans. This deficiency was identified for six out of thirteen sampled residents. The facility did not have a system in place to notify physicians of critical lab results, obtain ordered lab tests, and ensure medications were administered as prescribed. Specifically, the facility failed to notify the physician of a critically low hemoglobin level for a resident and did not document bleeding monitoring for two residents receiving anticoagulant therapy. Additionally, the facility did not obtain ordered weekly PT/INR levels for these residents. One resident, who had a history of Coumadin toxicity and gastrointestinal bleeding, was not monitored appropriately. The facility failed to obtain a PT/INR level and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to hospitalization for Coumadin toxicity. The resident required a blood transfusion and Vitamin K injection. This situation resulted in an Immediate Jeopardy finding due to the potential for more than minimal harm to residents requiring lab monitoring and physician notification. Other residents were also affected by the facility's deficiencies. One resident did not have their PT/INR levels drawn due to refusals and a lack of follow-up by staff. Another resident did not receive their prescribed medications and had missing documentation for blood glucose levels and vital signs. Additionally, routine laboratory draws were not completed for two residents, and a suprapubic catheter was not changed as ordered for another resident. These failures highlight the facility's lack of adherence to physician orders and monitoring protocols, leading to potential harm to residents.
Deficiencies in Lab Monitoring and Communication
Penalty
Summary
The facility failed to effectively administer its resources to ensure the highest practicable well-being of its residents, as evidenced by multiple deficiencies in monitoring and communication of laboratory results. Specifically, the facility did not have a system in place to ensure the completion of laboratory draws and timely communication of abnormal lab results to the provider. This failure affected several residents, including one who experienced an Immediate Jeopardy situation due to the facility's negligence in obtaining and communicating critical lab results. Resident #5, who had a history of Coumadin toxicity and gastrointestinal bleeding, was particularly affected. The facility failed to obtain a PT/INR level as ordered and did not notify the primary care physician of a critically low hemoglobin level. Despite these critical lab results, the resident continued to receive Coumadin, leading to a hospital transfer for a blood transfusion and Vitamin K injection. This oversight was discovered during a routine visit by the resident's PCP, highlighting the facility's failure to monitor and communicate critical lab results. Other residents were also impacted by similar deficiencies. Resident #12 did not have a PT/INR level drawn for over a month, yet continued to receive Coumadin without proper monitoring. Resident #9 had missed documentation of vital signs and medication administration, while Resident #10 and Resident #3 had lab tests that were not conducted as ordered. Additionally, Resident #4's suprapubic catheter was not changed according to the physician's schedule. These failures were acknowledged by the facility's Director of Nursing, who cited high turnover in leadership positions as a contributing factor to these care issues.
Failure to Provide Privacy and Address Resident Grievances
Penalty
Summary
The facility failed to provide a private space for the Resident Council Meeting held on 10/07/2024, which was conducted in the day room near the front entrance, nurses' station, and dining room. This area was open to anyone entering the facility, compromising the privacy of the meeting. During the meeting, a staff member conversed with the social services staff, and a visitor stood in the day room area, listening to part of the meeting. This lack of privacy was acknowledged by the facility's administrator and director of nursing. Additionally, the facility did not act promptly upon grievances voiced by residents during monthly Resident Council meetings. Residents consistently complained about staff not rounding every two hours, call lights not being answered timely, beds not being made, and CNAs being too loud at night. These issues were reported as ongoing problems that had not been addressed effectively, despite being raised in meetings from July to October 2024. The facility's response was limited to monthly in-service training for staff, with no other documented interventions.
Failure to Provide Diabetic Dietary Needs
Penalty
Summary
The facility failed to provide a resident with a diet specific to their special dietary needs and preferences, particularly for a diabetic precautions diet. Resident #1, who has a medical history including diabetes, diabetic neuropathy, hyperlipidemia, hypertension, schizophrenia, mood disorder, and intellectual disabilities, was not provided with an artificial sugar sweetener, Sweet'n Low, which is part of their dietary requirements. The resident reported not having access to Sweet'n Low for several days, which affected their ability to consume certain foods like grits and water with ice cubes. The deficiency was due to the dietary management's oversight in ordering and maintaining an adequate supply of artificial sweeteners. The dietary aide confirmed the absence of alternative sweeteners until the supply truck's arrival. The dietary manager admitted to overlooking the need to replenish the Sweet'n Low supply and failing to notify the office to purchase it locally. The administrator acknowledged that the dietary manager should have taken steps to ensure the availability of sugar substitutes for residents on diabetic precaution diets.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, who was assessed to be at risk for elopement, from exiting the facility without staff knowledge. The resident, who had moderate cognitive impairment and a history of wandering, was able to leave the facility unnoticed. This incident occurred when the resident asked an agency nurse to unlock the front door, expressing a desire to see his wife, while holding a trash bag with clothing items. The nurse did not notify other staff of the resident's exit-seeking behavior, and the resident was later found 0.4 miles away from the facility by staff from his Intensive Outpatient Program (IOP). The resident's medical records indicated a history of wandering and a risk for elopement, with interventions such as door alarms and hourly location monitoring in place. However, the agency nurse, who was not properly oriented to the facility's procedures or informed of the resident's elopement risk, failed to increase supervision or alert other staff members. The nurse signed off on the resident's location monitoring without accurately verifying his whereabouts, contributing to the resident's unsupervised departure. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's elopement risk. The facility's administrator acknowledged that the resident was not included in the elopement binder until after the incident, and there was no policy for training all staff, including agency staff, on elopement risks. The situation was further complicated by another resident's family moving belongings out of the facility, which may have distracted staff and allowed the resident to leave unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of its residents, specifically for a resident identified as being at risk for elopement. This resident, who was moderately cognitively impaired, managed to exit the facility unattended after asking an agency nurse to unlock the front door. The nurse did not inform other staff members of the resident's intention to leave. The resident was last seen at the nurses' station and was later found 0.4 miles away on a busy roadway by staff from the resident's Intensive Outpatient Program (IOP). The IOP staff notified the facility's Director of Nursing (DON), who then arranged for the resident's return to the facility. The incident highlighted a lack of effective supervision and communication among staff regarding residents at risk for elopement. The facility's administrator acknowledged that the resident was not placed in the elopement binder until after the incident, indicating a failure in the system to identify and monitor at-risk residents adequately. Additionally, there was no policy in place to ensure that all staff, including agency staff, were trained on identifying and managing residents at risk for elopement. This deficiency resulted in an Immediate Jeopardy situation, as the resident was able to leave the facility without proper supervision.
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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