St Joseph Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 2301 Sterlington Road, Monroe, Louisiana 71203
- CMS Provider Number
- 195359
- Inspections on file
- 34
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at St Joseph Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not use cleaning products effective against C. difficile in contact isolation rooms, and staff were unclear about proper procedures and product efficacy. Infection surveillance documentation was incomplete, with missing signs and symptoms and no documented surveillance plan, resulting in ineffective identification and tracking of communicable diseases. These failures had the potential to impact a large number of residents.
The facility did not document that residents or their representatives received education on the benefits and potential side effects of the COVID-19 vaccine, as required by facility protocols. This deficiency was confirmed through interviews and record reviews for several residents.
Two residents were found to be self-administering medications at their bedside without the required facility assessment or documentation. One resident was using a Ventolin inhaler independently, while another had a prescription oral rinse at bedside and confirmed self-use. Staff and the DON confirmed that neither resident had been assessed for self-administration as required by facility policy.
Two residents were not given the required SNF ABN (CMS-10055) before their Medicare Part A services were discontinued and they were discharged home, despite having benefit days remaining. Staff confirmed that the necessary notification was not provided to the residents or their responsible parties.
The facility did not send required discharge notices to the State Long-Term Care Ombudsman for two residents who were discharged, as confirmed by missing documentation and staff interviews. Emergency transfer logs were incomplete, only covering a single month, and prior records were not accessible.
A resident receiving medications and nutrition via PEG tube was found with a bedside syringe containing yellowish fluid, which was not cleaned or stored according to facility policy. The syringe and plunger were not separated and the syringe was not properly rinsed or dried after use, as confirmed by the DON.
Two residents with multiple medical conditions were provided bed rails without documented assessments for entrapment risk, despite facility policy requiring such evaluations before installation. Observations and record reviews confirmed the absence of necessary documentation, and facility administration acknowledged the deficiency.
A resident with multiple complex medical conditions was prescribed anticoagulant and anticonvulsant medications, but staff failed to consistently document required monitoring for side effects as ordered. Review of records and staff interviews confirmed that documentation was missing on several occasions while the resident was receiving these medications.
A resident's responsible party reported the theft of a phone charger to the ADON, but the facility failed to investigate or document the grievance, and no follow-up was conducted, despite the resident having severe cognitive impairment and the facility's policy requiring prompt resolution of grievances.
A resident with a Foley catheter and a history of UTIs was observed on multiple occasions with the catheter bag lying on the floor, contrary to facility policy requiring catheter bags to be kept off the floor. Staff confirmed the improper storage, and the resident's care plan did not specify this requirement, despite recent treatment for UTIs.
Nurses did not start a physician-ordered medication, Naltrexone, for a resident with severe dementia and hypersexual behavior, despite clear recommendations in the psychiatric evaluation and documentation in the medical record. The DON confirmed the medication was never initiated as ordered.
Three residents with complex medical and psychiatric needs were not permitted to return to the facility after hospitalization for psychiatric evaluation, despite being deemed stable for discharge. The facility did not document inability to meet their needs or provide required written notifications to the residents, their representatives, or the Ombudsman regarding the transfer/discharge and appeal rights.
A resident was admitted without documentation that they or their responsible party received information on resident rights and the temporary leave-bed hold policy. The administrator confirmed the absence of this documentation after being unable to locate the admission packet.
A resident was found with Fluticasone nasal spray at her bedside without an assessment or physician's order for self-administration, as required by facility policy. The resident, who was cognitively intact, stated she self-administered the spray daily. Facility staff, including an LPN and the DON, were unaware of the resident's possession and use of the medication, indicating a failure to adhere to the facility's procedures for self-administration of medications.
The facility failed to maintain clean and properly dated respiratory equipment for three residents. Observations showed dirty oxygen concentrator filters and undated nebulizer equipment. Despite multiple observations, these issues persisted, and the DON confirmed the deficiencies.
The facility failed to ensure residents were free from unnecessary medication use, as physicians did not provide rationale for continuing psychotropic medications without attempting gradual dose reductions (GDR). This deficiency was identified for multiple residents, including those with anxiety, depression, and dementia, where physicians disagreed with pharmacist recommendations for GDR but did not document their reasoning. This lack of documentation was confirmed by the DON.
A resident was found to have a bottle of Fluticasone nasal spray on the bedside table without a physician's order or assessment for self-administration. The facility's policy requires medications for self-administration to be stored in a locked area. Staff were unaware of the medication's presence, and the resident admitted to self-administering it.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in care. A resident's meal intake was not documented as required, another resident had medications at their bedside without proper assessment or orders, and a third resident had persistent hygiene issues without a care plan. These issues highlight lapses in care planning and monitoring.
The facility failed to provide adequate personal hygiene and ADL care for several residents, resulting in untrimmed and dirty fingernails and missed scheduled baths. Observations and interviews confirmed these deficiencies, affecting residents with varying levels of cognitive and physical impairments.
A resident with a history of falls and multiple medical conditions was found sitting on the floor in their room, but the required Accident/Incident report was not completed by the nursing staff. The facility's policy mandates immediate documentation of such incidents, which was not adhered to in this case, as confirmed by the DON.
The facility failed to assess residents for bed rail risks and did not obtain informed consent before installation. Multiple residents, including those with cognitive impairments and dependencies, had bed rails installed without proper documentation or consent. Observations and interviews confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, as required by their policy. A resident with a Foley catheter did not have EBP signage, and staff did not wear gowns when emptying the catheter bag. Two other residents with a hemodialysis line and tube feeding also lacked EBP signage. Another resident's room had EBP signage, but staff did not follow the policy, wearing only gloves instead of both gloves and a gown. The DON confirmed the policy was not followed.
A facility failed to maintain a record of a resident's personal belongings, including clothing, due to the absence of a system to document these items. The resident, who had multiple medical conditions and was dependent on staff, did not have an inventory of personal possessions in their medical record. Interviews with nursing staff confirmed the lack of an inventory sheet for the resident's belongings.
A resident on psychotropic medications missed a psychiatric appointment due to late transportation by the facility. The transportation driver reported the resident was not ready on time, leading to a delayed departure. Consequently, the resident arrived late and the appointment had to be rescheduled.
The facility did not have the most recent complaint survey results available for residents or families to review. The survey binder only contained the last annual survey results, and the absence of the latest complaint survey was confirmed by the DON.
A resident with multiple health conditions did not receive necessary lab tests, including hemoglobin A1C and lipid panel, despite orders from a Nurse Practitioner. The facility failed to follow through with the required monitoring, as confirmed by the DON.
A facility failed to provide timely care and treatment for a resident with a surgical wound from a hip fracture. The resident's surgical site was not assessed during admission, and there were no physician's orders for its care. The resident's staples were removed two months later, and the first orthopedic follow-up was delayed by ten weeks, beyond the typical 4 to 6 weeks post-surgery.
A resident in a LTC facility engaged in inappropriate sexual behavior towards two other residents, leading to a deficiency in protecting residents from abuse. The incidents involved sexual advances and misconduct, with one resident being cognitively intact and the other having moderately impaired cognitive skills. The facility's failure to prevent these incidents highlights a deficiency in their abuse prevention protocols.
The facility failed to notify responsible parties of significant changes in two residents' conditions. One resident's responsible party was not informed of the resident's passing, while another resident's responsible party was not notified of rescheduled psychiatric appointments due to transportation issues. The lack of documentation and communication was confirmed by facility staff.
A facility failed to document that a resident, who required extensive assistance with personal hygiene due to multiple medical conditions, received scheduled baths. Despite being cognitively intact, the resident's care plan required assistance with personal hygiene. However, there was no documented evidence of baths being provided as scheduled, as confirmed by interviews with a CNA and the DON.
A resident with limited range of motion and multiple diagnoses, including dementia and chronic kidney disease, was not provided with the prescribed soft braces while in bed, as observed during a survey. Despite physician orders and care plan instructions, staff failed to ensure the resident wore the necessary braces, leading to a deficiency in care.
The facility failed to administer medications per physician orders and document insulin administration. A resident received Glipizide despite low blood sugar levels, and another resident's sliding scale insulin administration was not documented, as confirmed by the DON.
Failure to Implement Effective Infection Control for C. difficile and Surveillance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the management of residents with confirmed or suspected Clostridioides difficile (C. difficile) infection. Housekeeping staff reported using cleaning products in contact isolation rooms that required specific contact times, but review of product labels and staff interviews revealed that none of the products in use were documented as effective against C. difficile. Additionally, there was confusion among staff regarding which products to use and their required contact times, and the Director of Nursing (DON) was unable to confirm the efficacy of products used on direct patient care equipment. The facility administrator later confirmed that the products being used were not effective against C. difficile infection. The facility also failed to properly identify and document possible communicable diseases or infections before they spread. Review of the infection surveillance report showed incomplete documentation, with missing signs and symptoms for numerous entries and a lack of categorization for infections. There was no documented infection surveillance plan, and staff were unable to provide evidence that effective infection surveillance was being performed. These deficiencies had the potential to affect 85 residents in the facility.
Failure to Document COVID-19 Vaccine Education for Residents
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for five residents reviewed. Specifically, there was no documented evidence in the medical records that these residents or their representatives received education about the benefits and potential side effects of the COVID-19 vaccine. This lack of documentation was confirmed by staff during interviews and record reviews. The facility's own protocols required education and documentation for all residents and staff, but this was not completed for the residents in question.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications as required by its policy. According to the facility's Self-Administration Medications policy, an assessment must be completed for each patient requesting to self-administer medications and repeated quarterly, with documentation kept in the medical record. For one resident with multiple diagnoses including polyosteoarthritis, morbid obesity, diabetes, COPD, and functional quadriplegia, observations revealed a Ventolin inhaler at the bedside, and the resident confirmed self-administration of the inhaler. Record review showed there was no facility assessment for this resident to self-administer medications, and the DON confirmed the absence of such an assessment. Another resident with diagnoses including aggressive periodontitis, anemia, type 2 diabetes with chronic kidney disease, and hemiplegia was observed with a prescription oral rinse at the bedside. The resident stated she used the mouthwash independently, and an LPN confirmed the oral rinse should not have been at the bedside. The DON also confirmed that this resident had not been assessed for self-administration of medication. In both cases, the facility did not follow its own policy to assess and document the appropriateness of self-administration for these residents.
Failure to Provide SNF ABN Prior to Discontinuation of Medicare Part A Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to two residents prior to the discontinuation of their Medicare Part A services. For both residents, records showed that Medicare Part A skilled services were ended while benefit days remained, and each resident was discharged home. There was no documented evidence that either resident or their responsible party received the SNF ABN before discharge. Interviews with the social worker and business office manager confirmed that the required notification was not given to the residents or their responsible parties prior to the termination of Medicare Part A services.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that copies of discharge notices were sent to the Office of the State Long-Term Care Ombudsman for two residents who were discharged. For one resident, records showed an admission and subsequent voluntary discharge against medical advice, but the facility's emergency transfer log only included notifications for December 2025, and staff confirmed that logs prior to that month were unavailable. For the second resident, records indicated multiple admissions and discharges, including a discharge to the hospital and later to home, but again, the emergency transfer log only covered December 2025, with no access to earlier records. Interviews with facility staff confirmed the lack of documentation and notification for these discharges.
Improper Cleaning and Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice by not properly cleaning and storing a piston syringe used for enteral feedings. Observation revealed that a resident's bedside syringe contained a yellowish fluid in the tip, was capped, and had the plunger inserted, contrary to facility policy. The policy required syringes used for liquids other than clear water to be rinsed, dried, and stored in a proper bag or approved container, with the syringe and plunger stored separately. The resident involved had multiple diagnoses, including diabetes, encephalopathy, muscle weakness, and communication deficits, and was receiving medications and nutritional support via a PEG tube. Interview with the DON confirmed that staff did not follow the proper cleaning and storage procedures for the syringe after use.
Failure to Assess Entrapment Risk Prior to Bed Rail Installation
Penalty
Summary
The facility failed to ensure that residents were assessed for the risk of entrapment prior to the installation of bed rails for two out of three residents identified as having side rails in use. According to the facility's own policy, an assessment should be conducted to determine the resident's symptoms, risk of entrapment, and the reason for using side rails. For both residents involved, there was no documented evidence that such an assessment was completed before bed rails were installed. One resident had multiple diagnoses, including acute and chronic respiratory failure, heart failure, COPD, dementia, and metabolic encephalopathy, and was observed with bilateral quarter rails in the up position. The resident's care plan and physician's orders indicated the use of assist rails as an enabler, but the medical record lacked documentation of an entrapment risk assessment. Another resident, with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, dementia, and major depressive disorder, was also observed with quarter bed rails in use. Similarly, the record for this resident did not contain evidence of an entrapment risk assessment prior to bed rail installation. Interviews with facility administration confirmed the absence of required documentation for both residents.
Failure to Document Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not consistently documenting the required monitoring for side effects of anticoagulant and anticonvulsant medications. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, atherosclerotic heart disease, hypertensive heart disease with heart failure, seizures, and diabetes mellitus, was prescribed Eliquis (an anticoagulant) and Levetiracetam (an anticonvulsant). Physician orders required monitoring for side effects of these medications every shift, and the resident’s care plan included interventions to monitor and document side effects and effectiveness of the medications. Record reviews revealed that the facility failed to document the required monitoring for side effects on multiple occasions in both November and December. Specifically, there was no documented evidence of monitoring for 13 instances in November and 5 instances in December, despite the resident receiving both medications during these periods. Interviews with nursing staff confirmed that the monitoring was not documented as ordered while the resident was on these medications.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance reported by the responsible party (RP) of a resident with severe cognitive impairment. The RP reported the theft of the resident's phone charger to the Assistant Director of Nursing (ADON) during a visit. Despite this report, there was no follow-up or investigation conducted by the facility, and the grievance was not documented in the facility's grievance or complaint logs. The ADON confirmed that the grievance was reported to her and acknowledged that she did not follow up with the RP or initiate an investigation. The resident involved had a history of schizophrenia, chronic kidney disease, depression, anxiety, dysphagia, and schizoaffective disorder, and was assessed as having severely impaired cognition. The facility's grievance policy required prompt investigation and resolution of grievances, including documentation and follow-up with the complainant. However, these procedures were not followed in this instance, resulting in the grievance not being addressed according to policy.
Failure to Maintain Proper Foley Catheter Bag Storage
Penalty
Summary
Surveyors observed that a resident with multiple medical conditions, including severe dementia, neuromuscular bladder dysfunction, and a history of urinary tract infections (UTIs), had a Foley catheter bag that was repeatedly found lying on the floor. The facility's own urinary catheter care policy, as presented by the DON, specifically requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated UTIs. Despite this, on two separate occasions, the resident's Foley catheter bag was observed on the floor, both times while the resident was under enhanced barrier precautions. Review of the resident's medical record confirmed the ongoing use of an indwelling catheter and documented recent treatment for UTIs, including one with E. coli. The resident's care plan included instructions to position the catheter bag and tubing below the bladder and away from the room entrance, but did not specify to keep it off the floor. During interviews, facility staff acknowledged that the catheter bag should not have been on the floor and confirmed the observations. The repeated failure to properly store the Foley catheter bag constituted a breach of infection control standards as outlined in the facility's policy.
Failure to Initiate Physician-Ordered Medication
Penalty
Summary
Nurses at the facility failed to initiate a physician-ordered medication, Naltrexone, for a resident with a history of severe dementia, psychotic disturbance, and hypersexual behavior, as documented in a psychiatric evaluation. The resident, who also had a PEG tube for nutrition and other significant diagnoses, was recommended to start a trial of Naltrexone 25 mg daily to address inappropriate behavior. Review of the resident's July 2025 medication administration record showed that the medication was never started as ordered. During an interview, the DON confirmed that the medication had not been initiated and acknowledged that it should have been.
Failure to Permit Return and Provide Required Discharge Notifications After Hospitalization
Penalty
Summary
The facility failed to ensure that three residents who were transferred to acute care hospitals for psychiatric evaluation were permitted to return to the facility after being deemed stable for discharge by hospital staff. In each case, the residents were not re-admitted to the facility, despite their readiness for return, and instead remained in the behavioral health facility or were transferred to other long-term care facilities. The facility required additional documentation and insurance authorization before considering re-admission, which resulted in the residents not being allowed to return. Additionally, there was no documentation in the medical records indicating that the facility was unable to meet the needs of these residents. The facility did not provide written notification to the residents, their responsible parties, or the Ombudsman regarding the transfer or discharge, nor did it inform them of their appeal rights as required by policy. Interviews with facility staff confirmed the absence of such documentation and notifications. The events involved residents with complex medical and psychiatric histories, including diagnoses such as acute kidney failure, dementia, schizophrenia, and behavioral disturbances. The lack of proper notification and failure to permit return after hospitalization were identified through record reviews and interviews with facility staff and external social workers.
Lack of Documentation for Resident Rights and Bed Hold Policy
Penalty
Summary
The facility failed to document that a resident or their responsible party received information regarding resident rights and the temporary leave-bed hold policy upon admission. Record review showed that the resident was admitted on a specific date, but there was no evidence in the medical records that the required information on resident rights and facility regulations was provided. During an interview, the administrator was unable to locate the resident's admission packet and confirmed that there was no documentation available to show that the resident or their responsible party had received the necessary information.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, specifically for a resident who was found to have a bottle of Fluticasone nasal spray at her bedside. The facility's policy requires an assessment to determine if a resident is capable of self-administering medications safely, and a physician's order must be obtained if self-administration is deemed appropriate. However, there was no such assessment or physician's order for this resident, who had been admitted with diagnoses including acute respiratory failure, disorder of the lungs, hypertension, and depression. The resident was cognitively intact, as indicated by a BIMS score of 15, and stated she self-administered the nasal spray daily. Observations over several days confirmed the presence of the nasal spray at the resident's bedside, and interviews with facility staff revealed a lack of awareness regarding the resident's possession and self-administration of the medication. The LPN and DON both confirmed that there was no order or assessment for the resident to self-administer the medication, and the nasal spray bottle was labeled from the hospital where the resident was previously admitted. This oversight indicates a failure to follow the facility's policy on self-administration of medications, as the necessary assessments and orders were not completed or documented.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for three residents. Observations revealed that the oxygen concentrator filters for two residents were dirty, and the oxygen tubing and humidification bottles were not dated or initialed. Despite multiple observations over two days, the filters remained unclean, and the issues with the oxygen tubing and humidification bottles were not addressed. The Director of Nursing confirmed these deficiencies during an observation. Additionally, the facility did not ensure that nebulizer equipment and tubing were dated and stored appropriately for two residents. Observations showed that the nebulizer masks and tubing were not dated or covered, and these issues persisted over two days. The Director of Nursing confirmed that the nebulizer equipment should have been dated and covered, indicating a failure to adhere to proper respiratory care protocols.
Failure to Document Rationale for Continued Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication use, as evidenced by the lack of rationale provided by physicians for the continuation of psychotropic medications without attempting gradual dose reductions (GDR). This deficiency was identified for five residents who were sampled for unnecessary medication review. The physicians or prescribers did not document a rationale for disagreeing with the pharmacist's recommendations for GDR, which is a requirement when continuing psychotropic medications. Resident #3 was admitted with multiple diagnoses, including anxiety disorder, schizoaffective disorder, and dementia with behavioral disturbance. The resident was prescribed several psychotropic medications, including Seroquel, Haloperidol, Buspirone, and Lorazepam, which required GDR. Despite recommendations from the pharmacist to reduce the doses of these medications, the physician disagreed without providing a rationale. This lack of documentation was confirmed by the Director of Nursing (DON). Similarly, other residents, including those with diagnoses such as depression, anxiety disorder, and dementia, were prescribed psychotropic medications that flagged for GDR. For instance, Resident #43 was on Mirtazapine, and Resident #51 was on Sertraline and Clonazepam, among others. In each case, the physician marked 'disagree' on the pharmacist's notes recommending GDR but failed to provide a rationale for their decision. This pattern of inaction and lack of documentation was consistent across all sampled residents, as confirmed by interviews with the DON.
Failure to Securely Store Self-Administered Medication
Penalty
Summary
The facility failed to securely store medications in a resident's room according to its policy and procedure for self-administering medication. Resident #323 was observed to have a bottle of Fluticasone nasal spray on the bedside table over several days, without a physician's order or assessment to determine if the resident was safe to self-administer the medication. The facility's policy requires that all medications for self-administration be stored in a locked storage area in the resident's room, and narcotics must be under double lock. Interviews with the LPN and the Director of Nursing revealed that they were unaware of the medication being in the resident's room. The LPN confirmed that there was no order for the resident to have the medication at the bedside and no assessment had been conducted. The medication label indicated it was from the hospital where the resident was prior to admission to the nursing facility, and the resident admitted to self-administering the medication without the facility's knowledge.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for several residents, leading to deficiencies in care. For one resident, there was no documentation of meal percentage intakes on multiple dates, despite the care plan requiring monitoring and documentation of food intake at each meal. This resident was dependent on staff for activities of daily living and had a significant change in their condition, including diagnoses of encephalopathy, epilepsy, and protein-calorie malnutrition. Another resident was observed to have medications at their bedside without a physician's order or an assessment to determine if they were safe to self-administer the medication. The facility's policy requires an assessment and a care plan for self-administration of medications, which was not completed for this resident. The resident had a nasal spray from a previous hospital stay, and the nursing staff was unaware of its presence in the room. Additionally, a resident with a BIMS score indicating cognitive intactness was found to have dirty fingernails over several days, with no care plan developed to address nail care. Despite observations and interviews confirming the need for nail cleaning, there was no documented evidence of a care plan to address this aspect of personal hygiene. These deficiencies highlight the facility's failure to ensure comprehensive care planning and implementation for its residents.
Deficiencies in Personal Hygiene and ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining personal hygiene. Observations, record reviews, and interviews revealed that seven out of eleven residents reviewed did not receive adequate care. Residents had issues with untrimmed and dirty fingernails, and some did not receive scheduled baths. For instance, resident #62, who was dependent on staff for ADLs, was observed with long fingernails that needed trimming. The Director of Nursing confirmed the need for nail care. Resident #45, who was cognitively aware and dependent on staff for various ADLs, reported not receiving baths as scheduled. Documentation showed that the resident missed scheduled baths multiple times over two months. Interviews with staff confirmed the lack of documentation and adherence to the bathing schedule. Similarly, resident #221, who required partial to moderate assistance with bathing, had no documented evidence of receiving baths for 22 days before discharge. Other residents, such as #16, #58, and #41, also exhibited issues with nail care. Resident #16, who was cognitively intact, had dirty fingernails despite receiving a bath. Resident #58, with severe cognitive impairment, had long, grimy fingernails, and resident #41, with moderate cognitive impairment, expressed dissatisfaction with the length of his nails. Staff interviews confirmed the responsibility for nail care and the need for attention to these residents' hygiene needs.
Failure to Complete Accident/Incident Report for Resident Found on Floor
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not completing an Accident/Incident report when a resident was found sitting on the floor. According to the facility's Accident/Incidents Policy, an Accident/Incident Report must be completed immediately upon staff becoming aware of an accident or incident involving a patient. However, when a resident was found sitting on the floor in their bedroom, no such report was completed, indicating a lapse in following the established protocol. The resident involved had a history of conditions including encephalopathy, hypertension, epilepsy, atrial fibrillation, malignant neoplasm, dehydration, and chronic pain. The resident's care plan noted a risk for falls due to weakness. Despite this, when the resident was found on the floor, the nurse assisted the resident without completing the necessary documentation. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the report should have been completed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risk of entrapment from bed rails and did not review the risks and benefits of bed rails with the residents or their representatives. Additionally, the facility did not obtain informed consent prior to the installation of bed rails for five out of six residents reviewed for accident hazards. The facility's policy requires that residents be assessed for potential risks associated with bed rails, and informed consent must be obtained after discussing the benefits and potential hazards with the resident or their representative. Resident #62, who was unable to complete a mental status interview and was dependent on staff for activities of daily living, had bed rails installed without a signed informed consent. Similarly, resident #31, with moderate cognitive impairment, had bed rails installed without a signed consent. Observations confirmed that both residents had bed rails raised and locked on multiple occasions, and interviews with the Director of Nursing (DON) confirmed the lack of signed consent. Resident #16, who was cognitively intact, and resident #40, also cognitively intact, both had bed rails installed without documented assessments or signed consents. Resident #9, who was cognitively intact but dependent on staff for assistance with activities of daily living, also had bed rails installed without an assessment or signed consent. Interviews with the DON confirmed the absence of necessary documentation and assessments for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for four residents who required such precautions due to their medical conditions. Resident #45, who had a Foley catheter, did not have the required EBP signage on their door, and staff were observed not wearing gowns when emptying the catheter bag, contrary to the facility's policy. Interviews with staff, including the Director of Nursing (DON), confirmed that the resident should have been on EBP and that signage should have been posted. Similarly, residents #321 and #322, who had a hemodialysis line and tube feeding, respectively, also lacked EBP signage on their doors, and staff were unaware of the need for these precautions. Resident #7's room had EBP signage, but staff did not adhere to the policy. A Certified Nursing Assistant (CNA) was observed wearing only gloves, not a gown, while emptying the resident's Foley catheter, despite the posted instructions requiring both gloves and a gown for such activities. The CNA stated she was instructed to wear only gloves, indicating a lack of proper communication and training regarding the facility's EBP policy. The DON confirmed that the policy required both gloves and a gown for this procedure.
Failure to Record Resident's Personal Belongings
Penalty
Summary
The facility failed to retain a resident's personal possessions by not having a system in place to record personal belongings. This deficiency was identified for a resident with multiple diagnoses, including encephalopathy, hypertension, epilepsy, and others, who was dependent on staff for activities of daily living. The resident's medical record did not contain an inventory of personal belongings, and interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the absence of such a record. The staff did not complete an inventory sheet for the personal items the resident brought or acquired during their stay.
Resident Misses Psychiatric Appointment Due to Late Transportation
Penalty
Summary
The facility failed to ensure that a resident received timely transportation to a psychiatric appointment, resulting in the appointment being missed and rescheduled. The resident, who is on psychotropic medications for depression, anxiety, and insomnia, had an out-of-town appointment scheduled with a psychiatrist at 9:00 a.m. However, the transportation driver reported that the resident was not dressed and ready when she arrived at work at 6:45 a.m., leading to a delayed departure from the facility at 7:36 a.m. Due to traffic, parking, and the preadmission process, the resident arrived late for the appointment and was unable to see the psychiatrist. The Director of Nursing confirmed that the resident should not have been late for the appointment. The failure to transport the resident in a timely manner was acknowledged by both the Director of Nursing and the transportation driver, resulting in the need to reschedule the appointment for a later date.
Missing Recent Complaint Survey Results
Penalty
Summary
The facility failed to ensure that the most recent state inspection results were available for review by residents or their families. Upon entering the facility, it was observed that the survey binder only contained the results of the last annual survey dated 09/13/2023. The results of the most recent complaint survey dated 08/16/2024 were missing from the binder. This was confirmed during an interview with the Director of Nursing, who acknowledged that the survey binder did not include the latest complaint survey results.
Failure to Conduct Necessary Lab Tests for Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not obtaining necessary laboratory tests. Resident #49, who was admitted with multiple diagnoses including type 2 diabetes mellitus, hypertension, and bipolar disorder, was supposed to have routine lab tests to monitor their condition. A Consultant Pharmacist recommended monitoring specific labs, including hemoglobin A1C and lipid levels, to ensure appropriate medication management. Despite receiving a verbal order from the Nurse Practitioner to conduct these tests every three to six months, the facility did not complete the hemoglobin A1C and lipid panel for the resident. The Director of Nursing confirmed that these tests were not performed as ordered, indicating a lapse in following through with the necessary medical monitoring for the resident's condition.
Failure to Provide Timely Care for Surgical Wound
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident admitted with a surgical wound. The resident, who was cognitively aware and required assistance with mobility and toileting, had a surgical wound from a left hip fracture. Upon review, it was found that the nursing admission assessment did not document the surgical wound, and there were no physician's orders for its care. The Director of Nursing confirmed that the surgical site was not assessed during admission, and the resident's staples were not removed until two months later. Additionally, the resident's first orthopedic follow-up occurred ten weeks after admission, which was significantly delayed compared to the usual 4 to 6 weeks post-surgery.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, leading to a deficiency in safeguarding residents' rights to be free from abuse. Resident #1, who was cognitively intact, was involved in inappropriate sexual behavior towards Resident #2 and Resident #3. The incidents involved Resident #1 making sexual advances and engaging in inappropriate sexual conduct in front of these residents. Resident #2, who was also cognitively intact, reported that Resident #1 engaged in sexual misconduct by masturbating in front of him and making inappropriate sexual comments. This incident left Resident #2 feeling upset and violated. The facility's records indicate that Resident #2 was immediately moved to a different room following the incident. Resident #3, who had moderately impaired cognitive skills, reported a similar incident where Resident #1 made inappropriate sexual propositions. Despite Resident #3's cognitive impairment, he was able to recount the incident to the staff. The facility's failure to prevent these incidents highlights a deficiency in their abuse prevention protocols, as Resident #1 was able to engage in such behavior on more than one occasion before being discharged.
Failure to Notify Responsible Parties of Resident Changes
Penalty
Summary
The facility failed to inform the responsible parties of two residents about significant changes in their conditions, violating resident rights. For one resident, the facility did not notify the responsible party when the resident passed away. The resident had a history of heart disease, chronic kidney disease, and other conditions, and was on hospice care with a Do Not Resuscitate status. Despite the resident's critical condition and eventual passing, there was no documented evidence that the responsible party was informed, as confirmed by the LPN and the Director of Nursing. In another case, the facility did not notify the responsible party of a resident when two psychiatric appointments were rescheduled. The resident, who was cognitively intact and required assistance with daily living, missed an appointment due to transportation issues. The facility's transportation driver was given an incorrect address, causing a delay and necessitating a reschedule. Additionally, a facility van was out of commission, leading to another missed appointment. The Director of Nursing and the Administrator confirmed the lack of notification to the responsible party regarding these changes.
Failure to Document Scheduled Baths for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good grooming and personal hygiene. The medical record for the resident, who had diagnoses including anemia, acute bronchitis, edema, anxiety, chronic kidney disease, schizoaffective disorder, dementia, and dysphagia, showed that they required extensive assistance with personal hygiene. Despite being cognitively intact with a BIMS score of 13, the resident's care plan included interventions for assistance with showers, shaving, oral, hair, and nail care per schedule and as needed. However, a review of the ADL Verification Worksheet for a specified period revealed no documented evidence that the resident received baths as scheduled. Interviews with a CNA and the DON confirmed that the resident was scheduled for bed baths on specific days and partial baths on others, but there was no documentation to support that these baths were provided as scheduled.
Failure to Provide Appropriate ROM Treatment for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, leading to a deficiency in care. Resident #6, who was admitted with multiple diagnoses including anemia, chronic kidney disease, and dementia, was identified as having limited range of motion and required assistance with activities of daily living. The resident's care plan indicated a risk for skin integrity and specified the use of a soft brace while in bed. Physician orders dated 11/08/2022 instructed that a brace be placed on the resident every evening and removed when out of bed. However, during an observation on 06/18/2024, it was noted that the resident was not wearing the prescribed soft braces while in bed, despite having foot drop in both feet. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident should have been wearing the soft braces while in bed. The Therapy Director also stated that the resident should wear soft braces in bed and metal braces when in a wheelchair. The failure to ensure the resident was wearing the appropriate braces as per the care plan and physician orders resulted in a deficiency in the care provided to the resident, potentially impacting their range of motion and overall well-being.
Failure to Administer Medications Per Orders and Document Insulin Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #1, who had multiple diagnoses including diabetes mellitus, was administered Glipizide 5 mg a total of 15 times during November 2023 when the resident's blood sugar was less than 110 mg/dL, contrary to physician orders. This was confirmed by the Director of Nursing (DON) during an interview. The resident's medical record indicated that blood sugar checks were to be performed four times a day, and Glipizide was to be held if the blood sugar was less than 110 mg/dL, which was not adhered to on multiple occasions. Additionally, the facility failed to document the amount of sliding scale insulin administered to Resident #2, who had diagnoses including hyperglycemia and dementia. The resident's care plan indicated a risk for hypoglycemia or hyperglycemia and required medications to be administered as ordered. Despite blood sugar readings that necessitated sliding scale insulin administration, the April 2023 Medication Administration Record (MAR) lacked documented evidence of the insulin amounts given. This deficiency was also confirmed by the DON during an interview.
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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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