Our Lady Of Wisdom Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 5600 General Degaulle Dr, New Orleans, Louisiana 70131
- CMS Provider Number
- 195509
- Inspections on file
- 21
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Our Lady Of Wisdom Community Care Center during CMS and state inspections, most recent first.
A resident with insomnia did not consistently receive prescribed Doxepin HCl at the scheduled time, with multiple documented instances of late administration well beyond the facility's one-hour policy window. The DON confirmed these delays, which were not in accordance with physician orders.
A resident with bilateral heel deep tissue injuries did not have heel protectors applied while in bed as ordered by the physician and outlined in the care plan. Multiple observations and interviews confirmed the devices were not used, and documentation was lacking to show compliance with the prescribed treatment.
Surveyors observed that a portable electric fan in the Hall B Mini Pantry had an accumulation of a light gray unknown substance on its grill. Both the Food Safety Manager and the Administrator confirmed that the fan should have been kept clean and sanitary, but it was not maintained appropriately, resulting in a deficiency related to food service area sanitation.
Two residents who were dependent on staff for toileting and had intact cognition were not provided incontinence care as requested before meal service. Despite staff being notified of their requests, care was withheld due to a practice of not providing incontinence care during meal times. Both residents were brought to the dining area and ate lunch without having their incontinence needs addressed, contrary to facility policy and their expressed preferences.
A CNA applied a medicated steroid ointment to a resident after receiving it from an LPN, despite facility policy requiring only licensed personnel to administer medications. Interviews with facility leadership confirmed that CNAs are not permitted to apply medicated ointments, and the practice was not in line with professional standards.
Two residents who were dependent on staff for toileting and incontinent care experienced significant delays in receiving assistance after requesting to be changed. Despite activating call lights and directly asking staff for help, both residents remained in soiled briefs for over two hours, as staff did not provide incontinence care during meal service. Staff interviews confirmed this practice, and both residents expressed discomfort with the delay.
Surveyors found medicated ointments and lotions, including Ammonium Lactate Lotion and Mometasone Furoate Ointment, stored in unlocked supply cabinets accessible to unauthorized individuals. Staff interviews revealed that these medications were not properly secured or labeled, and a CNA admitted to placing a resident's ointment in an unlocked cabinet due to an inability to administer it at the time. The facility administrator confirmed that these items should have been kept in locked storage.
A facility failed to ensure proper infection control practices during incontinent care for a resident. A CNA was observed not removing gloves or performing hand hygiene before using a clean wipe on a resident. Both the CNA and the DON acknowledged the lapse in protocol.
The facility failed to ensure food was not expired and stored in a sanitary manner, with expired items and improperly labeled food found in the pantry. Additionally, a nutritional supplement was not stored per manufacturer's guidelines, being left unrefrigerated and without a time of opening. The Food Service Manager and DON confirmed these deficiencies.
A facility failed to ensure a resident's advance directive was accurately reflected in their medical record, resulting in a discrepancy between the electronic medical record (EMR) and the physical chart. The EMR indicated a Do Not Resuscitate (DNR) order, while the physical chart showed a Full Code order. This inconsistency was confirmed by the S3MDS Nurse and the Director of Nursing (DON).
A resident's PEG tube feeding pole was observed to be unstable and leaning, posing a risk of falling over. Despite multiple observations of the issue, the equipment was not removed from service. Interviews with staff confirmed the equipment's instability and the oversight in addressing the problem.
A facility failed to accurately document the disposal of a controlled medication for a resident. The facility's policy requires that when a medication is not administered, it should be destroyed and documented by two nurses. However, a discrepancy was found in the records for a resident prescribed Norco, where a tablet was wasted but not documented, leading to an inaccurate count of the medication.
Failure to Administer Medication Timely
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for one resident. According to the facility's Medication Administration policy, medications are to be given within one hour of the prescribed time unless otherwise specified. Review of the clinical record for a resident with a diagnosis of insomnia showed a physician's order for Doxepin HCl 30mg to be administered at bedtime, specifically scheduled for 8:00PM. The resident's care plan also included an intervention to administer medications as ordered by the physician. Interviews and record reviews revealed that the resident frequently did not receive the sleeping medication on time, with administration times often significantly delayed. The medication administration audit report documented multiple instances where the medication was given more than one hour after the scheduled time, including some occasions where it was administered several hours late, such as after midnight or even in the early morning. The Director of Nursing confirmed these late administration times and acknowledged that the medication should not have been given so late.
Failure to Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A resident with a history of deep tissue injury to both heels was admitted to the facility and had a physician's order, as well as a care plan directive, for bilateral heel protectors to be applied while in bed. The resident was cognitively intact and dependent on staff for lower body footwear. Review of the electronic Medication Administration Record for the relevant month showed no documented evidence that heel protectors were applied as ordered. Multiple observations over several days revealed the resident lying in bed without heel protectors, with the devices found on a shelf in the room instead. The resident confirmed in interviews that staff had not been applying the heel protectors. The DON also acknowledged that the resident should have had the heel protectors on as ordered. There was no documentation or evidence provided by the facility to show that the physician's order and care plan were followed.
Unsanitary Portable Fan in Mini Pantry
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Hall B Mini Pantry, as observed by surveyors. During an inspection, a portable electric fan in the Hall B Mini Pantry was found to have an accumulation of a light gray unknown substance on its grill. This observation was confirmed by the Food Safety Manager, who acknowledged that the fan should have been kept clean and sanitary. The Administrator also confirmed that the fan should have been maintained in a clean condition. The deficiency was identified based on direct observation and staff interviews, with reference to the 2022 FDA Food Code regarding the importance of clean ventilation equipment in food service areas. No residents or specific patient conditions were mentioned in relation to this deficiency.
Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
Staff failed to provide incontinence care to two residents as requested prior to meal service, resulting in a lack of dignity and respect for their needs. Both residents had intact cognition and were dependent on staff for toileting due to mobility impairments and incontinence. The facility's policy required staff to check and provide incontinence care after each episode, but this was not followed in these instances. For one resident, the call light was activated to request a change before lunch. A staff member entered, turned off the call light, and stated help would be provided, but no care was given. The resident's request was relayed to the nurse and CNA, but the CNA did not provide care, stating that incontinence care was not performed during meal service. The resident remained unchanged through lunch, despite multiple staff being aware of the request. The second resident also requested to be changed before being brought to the dining area. The CNA acknowledged hearing the request but did not address it, instead bringing the resident to the dining table without providing care. Staff interviews confirmed that it was common practice not to provide incontinence care during meal times, citing infection control concerns. Both residents expressed a preference not to attend meals without being changed, and staff acknowledged that they would not want to be in a similar situation themselves.
Unlicensed Staff Administered Medicated Ointment
Penalty
Summary
The facility failed to ensure that only licensed personnel administered medications, as required by their policy and professional standards. During an observation, a cup containing a clear ointment was found in a cabinet, and a Certified Nursing Assistant (CNA) reported that she had applied the ointment to a resident's chest, abdomen, and groin. The CNA stated she had received the ointment from an LPN, who confirmed that the ointment was Mometasone Furoate 0.1%, a medicated steroid cream prescribed for the resident's psoriasis. The LPN indicated that it was common practice in the facility for CNAs to apply medicated ointments, despite the facility's policy stating only licensed or permitted individuals may administer medications. Interviews with the Interim Director of Nursing and the Minimum Data Set Clinical Coordinator confirmed that CNAs were not permitted to apply medicated ointments to residents. The administrator also acknowledged that the LPN should not have given the medicated ointment to the CNA for application. The resident involved had a physician's order for the medicated ointment to be applied once daily for psoriasis, but the administration of this medication by unlicensed staff was not in accordance with facility policy or professional standards.
Failure to Provide Timely Incontinence Care During Meal Service
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for toileting and personal hygiene. Both residents had care plans indicating total assistance was required for toileting due to mobility impairments and incontinence of bowel and bladder. Despite activating their call lights and directly requesting assistance from staff, both residents experienced significant delays in receiving incontinence care. For one resident, the call light was activated prior to lunch to request a change after a bowel movement. Although a staff member acknowledged the request and notified the appropriate personnel, the resident was not changed until over two hours later, after lunch had been served and meal trays were removed. During this period, the resident remained in soiled briefs, and staff interviews confirmed that incontinence care was not provided during meal service. The second resident also requested to be changed before being brought to the dining area for lunch. The request was acknowledged by staff, but the resident was taken to the dining room and left to eat lunch without being changed. The resident remained in soiled briefs for an extended period, with incontinence care not provided until more than two hours after the initial request. Staff interviews revealed a practice of not providing incontinence care during meal times, and both residents expressed discomfort and dissatisfaction with the delays.
Failure to Secure Medicated Ointments and Lotions in Locked Storage
Penalty
Summary
Surveyors observed that medicated ointments and lotions were not stored in locked compartments as required by facility policy and professional standards. Specifically, a bottle of Ammonium Lactate Lotion 12% was found on a shelf inside an unlocked supply cabinet accessible to residents, visitors, and unauthorized personnel. The prescription label on the bottle was partially removed, leaving no identifiable resident information or prescription number. Staff interviewed were unable to explain why the lotion was stored in this manner. Additionally, a medication cup containing a clear ointment was found in another unlocked cabinet. The cup had no identifying information, and a CNA admitted to placing it there because she was unable to apply the ointment to a resident at the time, believing the cabinet was a safe place for storage. An LPN confirmed that the ointment was Mometasone Furoate 0.1%, prescribed for a resident with psoriasis. The facility administrator acknowledged that these medicated products should have been stored in locked compartments and not in accessible supply cabinets.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident. During an observation, a Certified Nurse Assistant (CNA) was seen unfastening a resident's adult brief while wearing gloves but did not remove the gloves or perform hand hygiene before obtaining a clean wipe to clean the resident's buttock. The CNA acknowledged the failure to remove dirty gloves and perform hand hygiene before continuing care. The Director of Nursing also acknowledged that the CNA should have removed the dirty gloves, performed hand hygiene, and applied clean gloves.
Deficiencies in Food Storage and Nutritional Supplement Handling
Penalty
Summary
The facility failed to ensure that food was not expired and was stored in a sanitary manner. During an observation of the storage pantry, several expired food items were found, including packages of refried beans, a container of taco sauce, bread crumbs, and enchilada sauce. Additionally, an opened and undated container of blue cheese dressing was observed with an unidentified creamy and green fuzzy substance on its rim and outside. An undated open box of small pastries was also found without proper labeling. The Food Service Manager confirmed the presence of expired food and the unsanitary condition of the blue cheese dressing container, acknowledging that the pastries should have been dated and labeled. The facility also failed to store a nutritional supplement according to the manufacturer's guidelines. An LPN reported finding an opened carton of Med Pass 2.0 nutritional supplement on a medication cart without knowing when it was opened. The supplement was observed unrefrigerated and without a time of opening, despite the manufacturer's instructions to use it within 4 hours if not refrigerated. The DON confirmed that the supplement should have been labeled with the date and time of opening and discarded if not used within the specified time frame. The unrefrigerated supplement should not have been available for use on the medication cart.
Discrepancy in Resident's Code Status Orders
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was accurately reflected in their medical record. Specifically, there was a discrepancy in the code status orders for Resident #355. The electronic medical record (EMR) contained an order for Do Not Resuscitate (DNR), while the physical chart had an order for Full Code. This inconsistency was confirmed during interviews with the S3MDS Nurse and the Director of Nursing (DON), both of whom acknowledged that there should not have been a discrepancy in the resident's code status orders.
Unsafe PEG Tube Feeding Pole for Resident
Penalty
Summary
The facility failed to ensure that a resident's percutaneous endoscopic gastrostomy (PEG) tube feeding pole was in safe operating condition. Resident #46, who was dependent on staff for all activities of daily living and received all nutrition via a PEG tube, was observed multiple times with a feeding pole that leaned to the side and swayed back and forth when touched. This was noted during observations on four separate occasions, indicating a consistent issue with the stability of the equipment. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the equipment was unstable and should have been removed from service. The DON acknowledged that the PEG tube feeding pole was significantly leaning and had the potential to fall over, which was not addressed by the nursing staff. This oversight in maintaining essential equipment in safe working condition led to the deficiency identified in the report.
Inaccurate Documentation of Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain an accurate count of controlled medications for one of the residents reviewed for pharmaceutical services. According to the facility's Controlled Substance policy, when a resident's medication is not administered, it should be destroyed and documented by two nurses on the resident's individual narcotic record. However, a discrepancy was found in the medication records for a resident who had an order for Norco (Hydrocodone-Acetaminophen) 5-325 mg to be administered every 8 hours for pain. On a specific date, the records indicated an incorrect count of the remaining tablets after administration. The Director of Nursing (DON) confirmed that there was a discrepancy in the controlled substance record for the resident's Hydrocodone-Acetaminophen tablets. It was noted that a tablet was wasted by the nurse but was not documented on the resident's individual controlled substance record as required by the facility's policy. This failure to document the wastage of medication led to an inaccurate count of the controlled substances, which was not in compliance with the facility's procedures for handling controlled medications.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
