Riverview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bossier City, Louisiana.
- Location
- 4820 Medical Drive, Bossier City, Louisiana 71112
- CMS Provider Number
- 195497
- Inspections on file
- 25
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Riverview Care Center during CMS and state inspections, most recent first.
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 resident with severe cognitive impairment and a high risk for elopement was not provided with required elopement precautions by an LPN, including physician notification, application of a wander guard, and care plan updates. The resident subsequently left the facility unsupervised and was found by police two miles away, after crossing a major highway. Staff interviews confirmed the LPN did not follow protocol despite the positive risk assessment.
A resident with severe cognitive impairment and a known elopement risk was not provided with required precautions, such as a wander guard or care plan updates, after admission. An LPN completed the risk assessment but did not implement necessary interventions, leading to the resident leaving the facility unsupervised and being found by police miles away after crossing a major highway.
The facility did not post the most recent survey results in an accessible location for residents, family, or visitors. A resident with intact cognition, serving as the Resident Council President, was unaware of the survey results' location and her ability to review them. This was confirmed by the S2 Corporate Nurse, who admitted the results were not posted conspicuously.
The facility failed to ensure proper use and maintenance of bed rails by not conducting entrapment risk assessments or obtaining informed consent from residents or their representatives. Observations showed multiple residents with raised bed rails without necessary documentation. Interviews confirmed the absence of signed consents and proper assessments, posing a risk to resident safety.
The facility was found to have deficiencies in food service safety, including dirty kitchen equipment, improper storage of meal plates and saucers, and a flour scoop left inside the flour storage container. The Dietary Manager acknowledged these issues during an interview.
A facility failed to inform a resident with dementia and major depressive disorder about the risks, benefits, and side effects of an antipsychotic medication before administration. The resident, with moderately impaired cognition, received Aripiprazole as ordered, but there was no documentation confirming that the resident or their representative was informed about the medication. The DON confirmed the lack of documentation.
A facility failed to ensure a resident was free from physical restraints used for convenience, lacking written consent and a physician's order for a seatbelt, pommel cushion, scoop mattress, and side rails. The resident, with multiple medical conditions, could not remove the seatbelt herself, indicating it functioned as a restraint. The facility misclassified these items as devices, leading to the deficiency.
A facility failed to accurately assess a resident's discharge status, resulting in a documented discrepancy. The resident, admitted for aftercare following joint replacement surgery, was discharged home with family, but the discharge data inaccurately recorded it as unplanned and to a hospital. The MDS Coordinator confirmed the error during an interview.
The facility failed to provide necessary nail care for two residents unable to perform their own ADLs. One resident, with intact cognition, had brown debris under her nails after a shower, which staff did not clean. Another resident, with severely impaired cognition, had long, yellow nails with debris, observed on two occasions. An LPN confirmed the need for nail cleaning and trimming.
The facility failed to submit accurate staffing data to CMS, triggering a One Star Staffing Rating and Excessively Low Weekend Staffing for FY Quarter 3 2024. Despite providing more hours than required, the facility's PBJ Report indicated deficiencies. The HR representative confirmed that staffing data was sourced from the Cronos Payroll system, while the Administrator was unsure why the triggers occurred.
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.
Failure to Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to implement required elopement precautions for a resident identified as high risk for elopement upon admission. The resident, who had severe cognitive impairment as indicated by a low BIMS score and diagnoses including vascular dementia, was assessed as being at risk for elopement during the admission process. Despite this assessment, the LPN did not notify the physician or the resident's representative, did not apply a wander guard device, and did not update the care plan to reflect the resident's elopement risk, as required by facility policy. The resident subsequently eloped from the facility by following visitors out the front door while unsupervised. The absence of elopement precautions allowed the resident, who was ambulatory and severely cognitively impaired, to leave the premises without detection. Staff only became aware of the resident's absence after the resident's daughter reported her missing, prompting a facility-wide search and notification of the police. The resident was found by police approximately two miles from the facility, having crossed a four-lane divided highway. Interviews with facility staff confirmed that the LPN responsible for the initial assessment did not believe the resident was at risk for elopement, despite the positive screening, and therefore did not implement the required interventions. The director of nursing identified the failure to implement elopement precautions as the root cause of the incident.
Failure to Implement Elopement Precautions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement adequate supervision and accident prevention measures for a resident with severe cognitive impairment and a known risk of elopement. Upon admission, the resident was identified as being at risk for elopement through an assessment completed by an LPN. Despite this assessment, the required elopement precautions were not implemented. These precautions included notifying the physician and responsible party, placing a wander guard device on the resident, and updating the care plan to reflect the elopement risk. The resident's baseline care plan only included general interventions for cognitive loss and did not address the specific risk of elopement. On the day of the incident, the resident was last seen by a CNA after being escorted to her room. Later, the resident's daughter arrived and discovered that her mother was missing. Staff initiated a search, including a head count and checking all rooms, but were unable to locate the resident. The police were notified, and the resident was eventually found by law enforcement approximately two miles from the facility, having crossed a four-lane divided highway. The resident was returned to the facility and assessed by EMS, with no physical injuries noted. Interviews with facility staff revealed that the LPN who completed the elopement risk screening did not believe the resident was at risk, despite the assessment indicating otherwise. The LPN acknowledged that none of the required elopement precautions were implemented. The director of nursing confirmed that the elopement screening can be completed by floor nurses or the MDS nurse, and that all nurses are expected to follow the policy for residents identified as high risk for elopement. The failure to implement these precautions resulted in the resident being unsupervised and able to leave the facility without detection.
Failure to Post Survey Results Accessibly
Penalty
Summary
The facility failed to ensure that the most recent survey results were posted in a location that was easily accessible to residents, family, or visitors. During an observation, it was noted that the survey results were not displayed in a conspicuous place. A resident, who is the Resident Council President and has intact cognition as indicated by a BIMS score of 15, reported being unaware of where the survey results were posted and did not know she could review past survey results. This was confirmed by the S2 Corporate Nurse, who acknowledged that the survey results were not posted in a place where they could be easily found by residents, visitors, and family members.
Failure to Obtain Consent and Conduct Risk Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for several residents, as evidenced by the lack of proper assessments for the risk of entrapment and the absence of informed consent from residents or their representatives prior to the installation of bed rails. This deficiency was identified for 15 out of 17 residents reviewed for bed rail use. The facility did not conduct necessary entrapment assessments, nor did it obtain informed consent, which are critical steps in ensuring resident safety when bed rails are used. Observations revealed that multiple residents were found in their beds with bed rails raised, yet their medical records lacked documentation of informed consent or entrapment risk assessments. For instance, Resident #10, who had intact cognition, was observed with bed rails raised on multiple occasions, but no consent or assessment was documented. Similarly, Resident #18, with mildly intact cognition, and Resident #20, with intact cognition, were also observed with raised bed rails without the necessary documentation in their medical records. Interviews with residents and staff further confirmed the deficiency. Several residents reported using bed rails for mobility or positioning, yet they were not aware of any consent process or assessment conducted. The Director of Nursing and a Corporate Nurse confirmed that the facility did not have signed consents for bed rail use and that entrapment assessments were not completed correctly. This lack of compliance with safety protocols for bed rail use poses a significant risk to resident safety.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed that the large upright mixer was covered with crumbs and white powder, and the oven/warmer had dried food spills and streaks on its front. Additionally, resident meal plates and saucers were improperly stored in an upright position, and plate lids on the meal serving line contained food crumbs and dried food particles. Furthermore, a flour scoop was left inside the flour storage container, which is against proper food storage practices. During an interview, the Dietary Manager acknowledged these issues, confirming that the dirty kitchen equipment, incorrect plate storage, and improper storage of the flour scoop were problems that needed to be addressed.
Failure to Inform Resident of Antipsychotic Medication Risks
Penalty
Summary
The facility failed to ensure that a resident was informed of the risks, benefits, and side effects of an antipsychotic medication before its administration. The resident, who was admitted with diagnoses including dementia with psychotic disturbance and major depressive disorder, had a BIMS score indicating moderately impaired cognition. The resident's medical record showed an order for Aripiprazole, an antipsychotic medication, which was administered as prescribed. However, there was no documentation in the medical record to confirm that the resident or their representative had been informed about the medication's risks, benefits, side effects, or possible alternative treatments. During an interview, the Director of Nursing confirmed the absence of such documentation.
Failure to Obtain Consent and Physician's Order for Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience. Specifically, the facility did not have a written consent for the use of a self-releasing seatbelt, pommel cushion, scoop mattress, and side rails for the resident, nor was there a physician's order in place for these restraints. The facility's Restraint/Device Policy requires that any device that restricts freedom of movement and cannot be easily removed by the resident should be classified as a restraint, necessitating a physician's order and informed consent. However, the facility considered these items as devices rather than restraints, which led to the oversight. The resident in question has a medical history that includes spastic quadriplegic cerebral palsy, moderate intellectual disabilities, aphasia, major depressive disorder, bipolar disorder, mood affective disorder, and anxiety. Observations during the survey revealed that the resident was unable to remove the seatbelt herself, indicating that it functioned as a restraint. Despite this, the facility's staff, including the Corporate Nurse, did not classify the seatbelt, pommel cushion, or side rails as restraints, and thus did not obtain the necessary physician's order or consent. This misclassification and lack of proper documentation and consent led to the deficiency identified in the report.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to accurately assess a resident's discharge status, leading to a deficiency in the resident's assessment process. The medical record of a resident, who was admitted for aftercare following joint replacement surgery, indicated a discharge to home with family assistance. However, the discharge data collection form inaccurately documented the discharge as unplanned and to a short-term general hospital, which was incorrect. The resident left the facility with their sister in a private vehicle, taking a wheelchair they had brought upon admission. The MDS Coordinator acknowledged the error in the discharge MDS during an interview, confirming the discrepancy in the discharge documentation.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents who were unable to perform their own activities of daily living (ADLs). Resident #20, who has medical diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and fibromyalgia, was observed with brown debris under her nail beds after returning from a morning shower. Despite having intact cognition as indicated by a BIMS score of 13, Resident #20 reported that staff did not clean under her fingernails. This was confirmed by an LPN who noted the presence of brown debris under the resident's nails. Resident #104, with a BIMS score of 3 indicating severely impaired cognition, was also observed with long, yellow fingernails and brown debris under the nail beds on two separate occasions. The resident's care plan indicated a need for assistance with ADLs, yet the necessary nail care was not provided. An LPN confirmed the condition of Resident #104's nails, acknowledging that they needed to be trimmed and cleaned.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information to CMS as required. The Payroll Based Journal (PBJ) Report for Fiscal Year Quarter 3 2024 indicated triggers for a One Star Staffing Rating and Excessively Low Weekend Staffing. However, a review of the facility's weekend staffing pattern forms for the same period showed that the facility provided more hours than required and did not reveal any days with insufficient staffing hours. During interviews, the Human Resources representative stated that the staffing pattern forms were completed using data from the Cronos Payroll system, which is linked to the facility's fingerprint time clock. The Administrator expressed confusion over the triggers for excessively low weekend staffing, as the facility reportedly provided more hours than required.
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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