The Lodge At Tangi Pines
Inspection history, citations, penalties and survey trends for this long-term care facility in Amite, Louisiana.
- Location
- 10746 Hwy 16, Amite, Louisiana 70422
- CMS Provider Number
- 195349
- Inspections on file
- 20
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Lodge At Tangi Pines during CMS and state inspections, most recent first.
An LPN administered Humalog insulin to three residents and was observed drawing insulin from the vial without sanitizing the stopper first. The facility’s policy required medication administration in a manner that prevents contamination or infection, and the insulin insert stated the rubber stopper on multi-dose vials is not sterile and should be cleaned before use. The LPN confirmed the omission, and the DON stated vial stoppers should always be sanitized before insulin is extracted.
Surveyors observed multiple opened, undated food items stored improperly in the kitchen, including uncovered cups of ranch dressing and another undated food item in the snack/nourishment refrigerator, as well as an opened gallon of teriyaki sauce in the pantry that required refrigeration after opening but was not refrigerated. Staff confirmed opened foods should be covered, labeled with an open date, and refrigerated when required.
Failure to follow a resident's care plan for mechanical lift transfers. A resident with severe cognitive impairment, weakness, and non-ambulatory status required a mechanical lift with 2 staff for all transfers, but after a witnessed fall, a CNA manually transferred the resident back to bed alone before nurse assessment. The LPN and ADON confirmed the resident should have been transferred with the lift and 2 staff.
A resident with a history of falls and a right femur fracture had a witnessed fall in the room, followed by swelling, pain, and an x-ray confirming another fracture. The care plan listed a 2-CNA intervention for all care, but staff did not have that intervention in the CNA POC when assigned, and the MDS nurse stated it was not loaded when it should have been. The facility also had no record, log, or monitoring documentation showing which care plans were reviewed during QA.
Three residents with significant cognitive and physical impairments experienced multiple falls, but their care plans were not updated to include new fall prevention interventions after each incident. Staff confirmed that care plans remained unchanged despite documented falls, as shown in incident reports and nurse's notes.
A resident with severe cognitive impairment and a history of falls was not provided with non-skid socks as required by their care plan. Staff and the DON confirmed the omission, and the resident's representative also noted the absence of non-skid socks, despite this being a documented fall prevention intervention.
The facility failed to maintain accurate medical records for a resident with a Stage 3 pressure ulcer and functional quadriplegia. Multiple instances of missing documentation for wound care, catheter care, and medication administration were confirmed by staff, despite the tasks being performed as ordered.
The facility failed to maintain an infection control program, as staff did not practice proper hand hygiene and cleaning techniques during incontinence care for a resident. Two CNAs were observed handling clean items and touching the resident's belongings with soiled gloves, contrary to the facility's policies. Both CNAs admitted to not following proper procedures, and the DON confirmed that staff were trained to perform hand hygiene correctly.
The facility failed to ensure all complaint surveys since the last annual survey were available for resident review. An observation revealed that the survey results binder only contained the survey dated 05/05/2023, with no documented evidence of the complaint surveys from 07/12/2023, 03/20/2024, and 05/13/2024. The administrator confirmed the missing surveys should have been in the binder.
The facility failed to protect residents from psychosocial harm caused by a cognitively intact resident who exhibited inappropriate sexual behaviors. Despite being aware of the incidents, the staff did not take adequate measures to prevent further harm, resulting in residents feeling unsafe and fearful.
The facility failed to report an allegation of sexual abuse involving a severely cognitively impaired resident and a cognitively intact resident to the state agency as required by policy. Despite being informed of the incident, the DON and Administrator did not report it.
The facility failed to investigate an alleged incident of resident-to-resident sexual abuse. Despite multiple reports of inappropriate behavior by a resident, the DON and Administrator did not take action because they did not witness the incidents and did not believe the reports were credible.
The facility failed to update a resident's care plan to reflect specific inappropriate behaviors and necessary interventions, despite staff discussions highlighting these issues.
Failure to Sanitize Insulin Vial Stoppers During Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program when nursing staff did not sanitize insulin vial stoppers before drawing up insulin for three residents. The report states that the facility’s medication administration policy required medications to be administered in a manner to prevent contamination or infection, and the insulin manufacturer’s insert stated that the rubber stopper on multi-dose insulin vials is not sterile and should be cleaned before use to reduce contamination risk. Resident #3, Resident #7, and Resident #97 each had active physician’s orders for Humalog Insulin 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. On 04/13/2026, S4LPN was observed administering Humalog insulin to each of the three residents and extracted the insulin from the vial without sanitizing the stopper before use. During interview, S4LPN confirmed she did not sanitize the insulin vial stopper prior to extracting insulin for all three residents. S2DON later stated that insulin vial stoppers should always be sanitized prior to extracting insulin.
Improper Storage and Dating of Opened Food Items
Penalty
Summary
The facility failed to store foods under sanitary conditions by not ensuring that foods requiring refrigeration after opening were refrigerated and that opened food items were dated. During an initial tour of the kitchen, surveyors observed 27 uncovered, undated serving cups of ranch dressing and 1 uncovered, undated large cup containing a dark brown substance in the snack/nourishment refrigerator. In the pantry, surveyors also observed 1 opened, partially used gallon container of teriyaki sauce with no open date, despite a label stating it must be refrigerated after opening. The facility's policy required food to be clearly marked with the date or day by which it must be consumed or discarded, and staff interviews confirmed that opened food items should be covered and labeled with an open date and that foods requiring refrigeration after opening should be refrigerated.
Failure to Follow Mechanical Lift Transfer Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #68, who had diagnoses including a fracture of an unspecified part of the neck of the right femur, generalized muscle weakness, and Alzheimer's Disease. The resident's Quarterly MDS showed dependence on staff for chair/bed-to-chair transfers and a BIMS score of 03, indicating severe cognitive impairment. The current care plan stated the resident had self-care deficits related to needing assistance with ADLs, decreased mobility, dementia, and non-ambulatory status, and that a mechanical lift with 2 staff was to be used for all transfers. On 03/24/2026, the resident had a witnessed fall. The incident report included a witness statement indicating the resident rolled out of bed while a staff member was present and was transferred back to bed by that staff member before nurse notification or assessment. During interviews, the CNA stated the resident required a two-person mechanical lift for transfers, confirmed he was the only staff member present, and admitted he manually transferred the resident back to bed by himself and should not have. The LPN stated she responded to the fall and that the CNA transferred the resident from the floor to the bed before she assessed the resident, and the ADON confirmed the resident required the mechanical lift for all transfers with 2 staff members present.
Failure to Track and Communicate Fall Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to falls for Resident #68. The resident was admitted with diagnoses including a fracture of the unspecified part of the neck of the right femur, and the clinical record showed a witnessed fall on 03/24/2026 in the resident room. On 03/25/2026, nursing notes documented that the resident was screaming from bed, had swelling to the right upper thigh, guarded the area, and could not answer simple questions because of cognitive impairment. An x-ray was ordered and completed, and a fracture of the proximal femoral diaphysis just below the femoral neck was identified, after which the physician ordered transfer to the ER for evaluation and treatment. The resident’s care plan identified a fall risk with interventions including using 2 CNAs for all care and placing the bed against the wall with feet to the door after the fall. The facility’s quality improvement corrective action plan stated that care plans were not being updated and information was not being communicated to CNA staff about care plan changes. Although the facility reported that CNA tasks were entered into point-of-care and that CNAs could sign off on resident care, the documentation survey report showed that the two-CNA intervention was not consistently present in the CNA point-of-care record for Resident #68 until 04/14/2026. During interview, a CNA stated he was assigned to the resident but did not know two-person care was a fall intervention and could not locate that information on the tablet. The MDS nurse stated the intervention should have been loaded earlier and was not, and also stated there was no record, log, or monitoring documentation showing which resident care plans or interventions had been reviewed during the QA process.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for three residents following multiple documented falls. Each resident experienced one or more falls, as evidenced by incident reports and nurse's notes, but their care plans were not updated to reflect new or revised fall prevention interventions after these incidents. This lack of timely care plan revision was confirmed through record review and staff interviews. One resident with severe cognitive impairment and diagnoses including repeated falls, a progressive neurological condition, and Parkinson's Disease experienced three separate falls. Despite these incidents, the resident's care plan was not revised to address the specific circumstances or to implement new interventions after each fall. Staff interviews confirmed that the care plan remained unchanged prior to the survey. Another resident with Alzheimer's Disease and a history of falls, as well as a third resident with multiple fractures and neuropathy, also experienced falls that were not followed by updates to their respective care plans. In each case, staff acknowledged during interviews that the care plans should have been revised to reflect the falls and to include appropriate interventions, but this was not done prior to the survey team's review.
Failure to Implement Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a fall prevention intervention as identified in the care plan for a resident with a history of repeated falls, progressive neurological condition, and Parkinson's Disease with dyskinesia. The resident, who had severe cognitive impairment as indicated by a BIMS score of 3, was care planned to wear non-skid socks as a fall prevention measure following a previous fall incident. However, during observations, the resident was found wearing regular socks without non-skid bottoms. Multiple staff members, including nursing staff and the Director of Nursing, confirmed that the resident was a fall risk and that the care plan required the use of non-skid socks. Staff observed and acknowledged that the resident was not wearing the prescribed non-skid socks at the time of the survey. The resident's representative also reported that the resident does not wear non-skid socks, despite the documented intervention on the care plan.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for a resident reviewed for wound care. Specifically, the resident, who was admitted with diagnoses including a Stage 3 pressure ulcer and functional quadriplegia, had multiple instances where wound care, catheter care, and medication administration were not documented. The missing documentation dates included several days in March and April 2024, despite the tasks being performed as ordered according to staff interviews. Interviews with the Wound Care Nurse and the Director of Nursing confirmed the lack of documentation for the resident's wound care, Foley catheter irrigation, suprapubic catheter care, and Ampicillin administration. Both staff members acknowledged that the tasks were performed but not recorded, which is a violation of the facility's policy that requires timely and accurate documentation of all care services provided.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure that staff practiced proper hand hygiene and cleaning techniques during incontinence care for one of the residents reviewed. During an observation, two CNAs were seen performing peri-care on a resident without removing soiled gloves or performing hand hygiene at appropriate times. They handled clean items and touched the resident's belongings with soiled gloves, which is against the facility's infection control policies. The facility's policies on perineal care and hand hygiene were not followed by the CNAs during the observed incident. Both CNAs admitted in interviews that they did not remove their soiled gloves or perform hand hygiene as required. The Director of Nursing confirmed that staff were trained to perform hand hygiene correctly and should have done so during the peri-care. The failure to adhere to these policies was observed and confirmed through interviews with the involved staff and the Director of Nursing.
Failure to Provide Complaint Survey Results for Resident Review
Penalty
Summary
The facility failed to ensure all complaint surveys since the last annual survey were available for resident review. An observation on 05/20/2024 at 9:07 a.m. revealed that the survey results binder near the entrance of the facility only contained the survey dated 05/05/2023. There was no documented evidence of the complaint surveys from 07/12/2023, 03/20/2024, and 05/13/2024 being available for review. During an interview on 05/20/2024 at 9:40 a.m., the administrator confirmed that the complaint surveys since the annual recertification survey should have been in the binder but were not.
Failure to Protect Residents from Psychosocial Harm
Penalty
Summary
The facility failed to protect residents from psychosocial harm caused by a cognitively intact resident, Resident #3, who exhibited inappropriate sexual behaviors towards other residents. Resident #3 was observed kissing Resident #1, a severely cognitively impaired resident, on the cheek without consent. Despite being aware of Resident #3's behaviors, the facility's staff, including the Director of Nursing (DON) and the Administrator, did not take adequate measures to prevent further incidents. Interviews with other residents revealed that they felt unsafe and were afraid of Resident #3 due to his inappropriate actions. Resident #1, who has diagnoses including Vascular Dementia and Major Depressive Disorder, was unable to consent to or understand the actions of Resident #3. Multiple incidents were reported where Resident #3 made inappropriate advances towards Resident #1, including leading her towards his room and making inappropriate comments. Staff members, including Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), witnessed these behaviors and reported them to the DON and the Administrator. However, the facility's response was insufficient, and Resident #3 continued his inappropriate actions. Other residents, such as Random Resident #4, Random Resident #5, and Random Resident #7, expressed fear and discomfort due to Resident #3's behavior. They reported feeling unsafe and took measures to protect themselves, such as keeping a walking stick by their bedside. Despite these concerns, the facility did not implement effective supervision or intervention to ensure the safety and well-being of the residents. The failure to address Resident #3's behavior resulted in ongoing psychosocial harm to the affected residents.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure an allegation of sexual abuse was reported immediately to the facility Administrator and the State Survey Agency. The policy required that abuse be reported immediately, but not later than 2 hours after the allegation is made. However, the facility did not report an incident involving Resident #3 and Resident #1. Resident #1, who was severely cognitively impaired with a BIMS of 4, was allegedly kissed by Resident #3, who was cognitively intact with a BIMS of 15. Resident #3 also made inappropriate sexual comments and gestures about Resident #1 to another resident. Despite being informed of these allegations, the Director of Nursing (S2DON) and the Administrator (S1ADM) did not report the incident to the state agency as required by the facility's policy. Interviews revealed that another resident informed the S2DON about the incident, but he did not report it because he did not witness it. Additionally, the S1ADM confirmed he was aware of the allegations but had not reported them. The failure to report the incident immediately as per the facility's policy resulted in a deficiency in ensuring the safety and protection of the residents involved.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure an alleged incident of resident-to-resident sexual abuse was thoroughly investigated. The facility's policy mandates an immediate investigation when reports of abuse occur, including identifying and interviewing all involved persons and providing thorough documentation. However, the facility did not complete any investigation documentation for Resident #3, despite multiple reports of sexually inappropriate behavior. Resident #3 allegedly made sexual comments and gestures to another resident and was reported to have kissed Resident #1. These incidents were brought to the attention of the Director of Nursing (DON) and the Administrator, but neither took action to investigate because they did not witness the incidents themselves and did not believe the reports were credible. Interviews with staff and residents confirmed that the inappropriate behaviors were reported to the DON and the Administrator. The DON admitted that he did not report or investigate the incident because he did not witness it and did not believe it happened. Similarly, the Administrator acknowledged being aware of the complaints but dismissed them as exaggerations and did not see a need to investigate. This lack of action and failure to follow the facility's policy resulted in the deficiency noted in the report.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #3, who exhibited inappropriate behaviors. The medical records indicated that Resident #3 was admitted on an unspecified date and had a care plan noting inappropriate behaviors without specifying the types of behaviors or interventions. During a staff meeting, concerns were raised about Resident #3 taunting and blowing kisses at female residents. Despite these discussions, the care plan was not updated to reflect specific behaviors or the agreed-upon interventions, such as increased supervision. Both the Minimum Data Set Coordinator (S3MDS) and the Director of Nursing (S2DON) confirmed that the care plan should have been updated but was not.
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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