Progressive Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 2550 Kings Hwy, Shreveport, Louisiana 71103
- CMS Provider Number
- 195136
- Inspections on file
- 23
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Progressive Care Center during CMS and state inspections, most recent first.
A resident with a recent R BKA and L toe amputation did not receive wound care assessment or documented treatment upon admission. The resident reported surgical dressings were not changed for 5 days, and the Corporate Director and MDS Nurse confirmed the wound care assessment and treatment were not completed until several days after admission and after the orders were entered.
The facility failed to maintain infection control practices during medication administration and blood glucose monitoring. An LPN did not perform hand hygiene between resident contacts or before checking a resident’s blood glucose, and did not disinfect the glucometer after use. A second LPN also failed to perform hand hygiene before medication administration for another resident, and both LPNs confirmed the missed hand hygiene practices.
A resident with moderate cognitive impairment and diagnoses including lung CA, gout, and atrial fibrillation was observed with long fingernails extending past the fingertips and brown substance under the nails. The resident said food gets stuck under the nails and expressed unhappiness with their condition. The DON confirmed the fingernails should have been cleaned and trimmed during ADL care.
A facility failed to ensure appropriate dialysis care for a resident by not assessing and monitoring the dialysis access site every shift, as required by their policy. The resident, with end-stage renal disease and dependent on dialysis, had no documentation of site assessments in their medical record. Interviews with an LPN and the DON confirmed the lack of documentation and the requirement for regular monitoring.
The facility failed to assess residents for entrapment risk, obtain informed consent, and document bed rail use in care plans and physician orders for several residents. Observations and interviews confirmed the use of bed rails without proper assessments or consent, violating facility policy.
A facility failed to monitor a resident's drug regimen, specifically for bleeding while on Eliquis and for behaviors and side effects while on Celexa. The resident, with a history of depression and heart disease, was not monitored for bleeding on specific dates and lacked monitoring for antidepressant side effects over several days. Interviews confirmed the absence of required monitoring, indicating non-compliance with the care plan.
The facility failed to implement Enhanced Barrier Precautions for two residents with wounds and indwelling devices. A resident with severe cognitive impairment and an unhealed pressure ulcer lacked EBP signage and PPE. Another resident with a stage 2 pressure ulcer also lacked EBP signage and gowns. During wound care, a nurse wore a sleeveless PPE gown, which did not provide full coverage. These deficiencies indicate a lapse in infection control measures.
A resident with a history of cerebral infarction reported being verbally and physically abused by a CNA, who used derogatory language and handled the resident roughly during transfers. The facility's abuse policy requires prompt reporting, but not all staff completed the necessary in-service training on abuse and neglect following the incident. The CNA involved is no longer employed at the facility.
A resident with a history of significant medical conditions was left unsupervised during a whirlpool bath, contrary to the facility's policy. The resident confirmed the incident, and a CNA later found and assisted the resident. The facility's administrator acknowledged the lapse in supervision.
Delayed Wound Care Assessment and Treatment
Penalty
Summary
The facility failed to ensure Resident #69 received wound care treatment in accordance with physician orders and professional standards of practice. The resident was admitted with diagnoses including status post right below-knee amputation and status post left trans-metatarsal toe amputation, and had a BIMS score of 15 indicating intact cognition. During interview, the resident reported that the surgical dressings on the right BKA site and left toe amputation site were not changed for 5 days until 03/25/2026. The physician's orders for wound care were dated 03/25/2026, with daily care ordered for the right BKA site and every-2-day care ordered for the left 5th toe amputation site. The Corporate Director confirmed the wound care assessment was completed on 03/25/2026, 5 days after admission, and that wound care treatment was not documented until that date. The MDS Nurse confirmed the resident should have had a wound care assessment and wound care treatment upon admission.
Infection Control Lapses During Medication Administration and Glucose Monitoring
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff followed hand hygiene and equipment disinfection practices during resident care and medication administration. During a medication administration observation, an LPN did not perform proper hand hygiene after each resident and before checking a blood glucose level for one resident, and did not disinfect the glucometer after use. The LPN later confirmed that hand hygiene was not performed prior to and in between resident contact during medication administration and that the glucometer was not cleaned between residents. During another medication administration observation, a different LPN did not perform proper hand hygiene before administering medications to another resident. That LPN later confirmed hand hygiene was not performed prior to medication administration and stated it should have been. The report also notes facility policies requiring hand hygiene before preparing or handling medications, after removing gloves, and disinfection of durable medical equipment, including glucometers, before and after resident use.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received needed services to maintain good personal hygiene. The facility’s Care of Fingernails/Toenails policy stated nail care includes needed cleaning and regular trimming. Resident #60 was admitted with diagnoses including lung cancer, gout, and atrial fibrillation, and had a BIMS score of 12 indicating moderate cognitive impairment. During an observation, Resident #60 was found with long fingernails extending past the fingertips on both hands and brown substance under the fingernails. The resident stated feeling unhappy with the long fingernails and reported that food gets stuck underneath the nails and that the fingernails should be trimmed. A later observation again showed the same condition, and the DON confirmed the resident’s fingernails were long with brown substance under them and should have been cleaned and trimmed during ADL care.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident requiring such services, specifically in the assessment and monitoring of the dialysis access site. The facility's policy mandates that the dialysis access site, such as an AV shunt or graft, should be checked every shift for a bruit and thrill, and monitored for signs of infection. However, a review of the medical records for a resident with end-stage renal disease and chronic kidney disease, who was dependent on renal dialysis, revealed a lack of documentation indicating that the dialysis access site was assessed and monitored every shift as required. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of documentation for the required assessments and monitoring of the resident's dialysis access site. The LPN acknowledged that the resident's dialysis access site was located in the left upper arm and confirmed the lack of documentation in the medical record. The Director of Nursing also confirmed that dialysis access sites should be assessed and monitored every shift, and verified the absence of such documentation in the resident's medical record.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risk of entrapment before the installation and use of bed rails. This deficiency was identified for seven residents, all of whom had bed rails in use without documented entrapment risk assessments. The facility's policy requires an assessment to determine the resident's symptoms or reasons for using side rails, but this was not completed for any of the residents reviewed. Additionally, the facility did not obtain informed consent from the residents or their representatives for the use of bed rails. The policy mandates that consent for using restrictive devices must be obtained per facility protocol, yet this step was overlooked. Observations revealed that residents were using bed rails without the necessary consent, and interviews with staff confirmed the lack of documentation and consent. Furthermore, the residents' comprehensive care plans and physician orders did not include the use of bed rails as an assistive device. The facility's procedure requires that the use of side rails be addressed in the resident care plan and that a physician order be obtained. However, reviews of the medical records for the seven residents showed no such documentation, indicating a systemic failure to adhere to the facility's guidelines and regulatory requirements.
Failure to Monitor Anticoagulant and Antidepressant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically in the monitoring of an anticoagulant and an antidepressant. Resident #148, who was admitted with diagnoses including depression, atherosclerotic heart disease, heart failure, and the presence of a cardiac pacemaker, was prescribed Eliquis and Celexa. The Medication Administration Record (MAR) for February 2025 showed that monitoring for bleeding was not conducted for the morning doses of Eliquis on February 21, 22, and 24, and the evening dose on February 24. Additionally, there was no evidence of monitoring for behaviors and side effects related to the antidepressant Celexa from February 21 to February 24. The resident's care plan included approaches to evaluate the effectiveness of the antidepressant therapy and to monitor for suicidal ideation and patterns of target behaviors. It also included administering medication as ordered and documenting adverse reactions for the anticoagulant. However, interviews with the Director of Nursing and a Registered Nurse confirmed the lack of evidence for the required monitoring during the specified dates, indicating a failure to adhere to the care plan and physician orders.
Inadequate Infection Control Measures for Residents Requiring Enhanced Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for two residents. Resident #32, who had severe cognitive impairment, an unhealed pressure ulcer, and an indwelling catheter, did not have EBP signage on the door or personal protective equipment (PPE) readily available. The Assistant Director of Nursing confirmed the absence of necessary precautions for Resident #32, acknowledging the need for PPE and signage. Similarly, Resident #149, with a stage 2 pressure ulcer, was not provided with EBP signage or gowns on the hall. The Treatment Nurse and LPN confirmed the absence of these precautions. During wound care, the Treatment Nurse wore a sleeveless PPE gown, which did not provide full arm coverage, a fact acknowledged by both the Treatment Nurse and the Director of Nursing. These deficiencies highlight the facility's failure to implement and maintain proper infection control measures for residents requiring enhanced precautions.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by a staff member. The resident, who had a history of cerebral infarction and required assistance with transfers, reported being verbally and physically abused by a CNA. The resident's grievance report detailed that the CNA used derogatory language and handled the resident roughly during transfers. The resident expressed a desire not to be cared for by this CNA anymore. The facility's abuse policy mandates prompt reporting of any abuse incidents, but the in-service training on abuse and neglect was not completed by all staff following the incident. Interviews with the Director of Nursing and the Administrator confirmed that not all staff participated in the required training after the incident. The CNA involved in the incident left the facility and was no longer employed there.
Resident Left Unsupervised During Whirlpool Bath
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during a whirlpool bath, leading to a deficiency. The facility's policy mandates that residents should never be left unattended during a bath or whirlpool session. However, on 04/12/2024, a resident with a history of acquired absence of the left leg below the knee, type 2 diabetes mellitus with neuropathy, and hypertensive heart disease was left alone in the whirlpool room. The resident, who had a BIMS score of 15 indicating intact cognition and required partial/moderate assistance with bathing, confirmed being left alone in the whirlpool a few weeks prior to the interview on 05/06/2024. Further investigation revealed that a CNA found the resident alone in the whirlpool and assisted them out. The facility's administrator confirmed that the resident had been left unsupervised, which was against the facility's policy. This incident highlights a lapse in following established procedures designed to ensure resident safety during bathing activities.
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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