The Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Louisiana.
- Location
- 1000 Mckeen Place, Monroe, Louisiana 71201
- CMS Provider Number
- 195542
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Oaks during CMS and state inspections, most recent first.
Surveyors found that the facility failed to conduct and document required quarterly care plan meetings, resulting in three residents and/or their responsible parties not being invited to participate in the development and implementation of person-centered care plans. One resident with multiple medical conditions and intact cognition had no evidence of any quarterly care plan meetings before death in the hospital. Another resident with severe cognitive impairment and complex diagnoses had not had a care plan meeting since an earlier documented session, and a third resident with moderate cognitive impairment and multiple chronic conditions also had no quarterly care plan meetings scheduled. The SSD acknowledged she had not scheduled these meetings, and the DON confirmed that the facility did not conduct them.
The facility failed to follow its abuse and injury reporting policy by not immediately informing the Administrator of an unwitnessed fall that resulted in serious bodily injury. A resident with multiple medical conditions, intact cognition, and no recent falls was found by an LPN lying face down on the floor, unresponsive, with a hematoma and laceration to the head and blood on the floor, and was sent to the ER where the resident later died. The DON was notified around shift change and then contacted the Corporate Administrator later that morning, but only reported that the resident had a fall, omitting that it was unwitnessed and involved serious head trauma, contrary to the requirement to report such events within two hours with full details.
A resident with a history of severe medical conditions and a Stage 4 pressure ulcer developed six unidentified pressure ulcers on the feet, which were not reported or treated by the wound care nurses or floor nurse. The resident's feet also showed signs of neglect, with a buildup of peeling skin. The Director of Operations and DON were informed of these findings.
A resident with moderate cognitive impairment and identified as an unsafe smoker was repeatedly found smoking in their room and improperly disposing of cigarette ashes, contrary to the facility's smoking policy. Despite the care plan noting the need for supervision, the resident was observed smoking without a smoking apron and without staff supervision, leading to a deficiency in maintaining a safe environment.
A facility exceeded the acceptable medication error rate, reaching 6.25%. An LPN failed to administer Citracal-D3 to a resident due to unavailability and administered an incorrect dosage of Lisinopril, giving 20mg instead of the prescribed 10mg. The DON confirmed the errors and acknowledged the need for adherence to physician orders.
The facility failed to maintain personal hygiene for two residents. A resident with severe vascular dementia had a dirty hand mitt and untrimmed fingernails, while another with Parkinson's disease had long, jagged toenails. The DON confirmed the deficiencies, indicating a lapse in adhering to the facility's Nail Management Policy.
Failure to Involve Residents and Representatives in Quarterly Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their responsible parties were allowed to participate in the development and implementation of person-centered plans of care by not scheduling required quarterly care plan meetings. For Resident #1, who was admitted with multiple diagnoses including unspecified atrial fibrillation, right rib fractures, type 2 diabetes mellitus, stroke, hypertension, and age-related osteoporosis, record review showed no documented evidence of any quarterly care plan meetings prior to the resident’s death in the hospital. The Quarterly MDS for this resident showed a BIMS score of 13, indicating no cognitive impairment, yet there was no documentation that the resident had been invited to or participated in quarterly care plan meetings. For Resident #2, admitted with conditions including conversion disorder with seizures or convulsions, severe unspecified dementia with behavioral disturbance, vascular dementia with agitation, malignant neoplasm of the prostate, acute kidney failure, depressive episodes, repeated falls, and other specified mental disorders, the Quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment. The SSD stated she was responsible for scheduling quarterly care plan meetings but had not scheduled any for this resident, and the last care plan meeting on record was several months earlier. For Resident #3, admitted with Bell’s palsy, chronic pain syndrome, paroxysmal atrial fibrillation, GERD, chronic diastolic heart failure, major depressive disorder, trigeminal neuralgia, generalized anxiety disorder, metabolic encephalopathy, and Parkinson’s disease, the Quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The SSD similarly confirmed she had not scheduled any quarterly care plan meetings for this resident. In all three cases, the DON confirmed the facility failed to conduct the required care plan meetings.
Failure to Timely Report Unwitnessed Fall With Serious Head Injury
Penalty
Summary
The facility failed to ensure that an allegation of an injury of unknown source with serious bodily injury was reported immediately, or within two hours, to the Administrator as required by its abuse, neglect, exploitation, or misappropriation reporting policy. The policy specified that all suspected abuse, neglect, exploitation, misappropriation, or injuries of unknown source must be reported immediately to the Administrator and appropriate authorities, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. For one resident, the Director of Nursing (DON) was notified around 7:00 a.m. by an LPN that the resident had been found on the floor unresponsive with a hematoma to the right side of the head and a laceration to the back of the head, but the DON did not convey the seriousness and unwitnessed nature of the incident when notifying the Corporate Administrator. The resident involved had been admitted with diagnoses including unspecified atrial fibrillation, right-sided rib fractures, type 2 diabetes mellitus without complications, stroke, hypertension, and age-related osteoporosis without current pathological fracture. A recent Quarterly MDS showed a BIMS score of 13 (no cognitive impairment), supervision or touching assistance needed for bed mobility, transfers, and toileting, partial/moderate assistance for bathing, no functional ROM limitations, and no recent falls. On the morning of the incident, the LPN found the resident lying face down on the floor, unresponsive, with visible head injuries and blood on the floor, and sent the resident to the emergency room, where the resident later expired. The DON notified the Corporate Administrator at 9:15 a.m. but only reported that the resident had a fall, omitting that it was unwitnessed and resulted in serious bodily injury, and the Corporate Administrator confirmed he should have been notified immediately of the unwitnessed fall with serious bodily injury.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who was admitted with a history of transient ischemic attack, cerebral infarction, severe vascular dementia, primary open-angle glaucoma, cerebral palsy, and a Stage 4 pressure ulcer on the right hip, developed six unidentified pressure ulcers on the feet. During a wound care session, deep tissue injuries were observed on both feet, including the great toe, heel, and ankle, which had not been previously identified or reported by the wound care nurses or the floor nurse. Additionally, the resident's feet showed signs of neglect, with a thick, flaky, and crusty buildup of peeling skin between the toes, indicating a lack of proper hygiene and care. The wound care nurses and the floor nurse confirmed their unawareness of the new pressure ulcers, and the Director of Operations and Director of Nursing were informed of these findings. This lack of awareness and reporting contributed to the deficiency in providing adequate pressure ulcer care and prevention for the resident.
Failure to Supervise Unsafe Smoker
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as an unsafe smoker. The resident, who had a history of type 2 diabetes mellitus, cellulitis, alcohol dependence, noncompliance with medical treatment, repeated falls, hypertension, and nicotine dependence, was assessed to have moderate cognitive impairment. Despite being identified as an unsafe smoker, the resident was found smoking in his room on multiple occasions, which was against the facility's smoking policy. The care plan noted the resident's potential for injury related to smoking, yet incidents of smoking in the room were recorded on several dates, and a care plan meeting was held with the resident's sister and ombudsman to address these issues. Observations revealed that the resident was not wearing a smoking apron and was placing cigarette ashes and butts in a garbage can with a plastic liner, which posed a fire hazard. No staff were present to monitor the resident during these times, despite the facility's policy requiring direct supervision for residents with restricted smoking privileges. Interviews with staff confirmed the resident's unsafe smoking behavior and the facility's failure to adhere to its smoking policy, which contributed to the deficiency in providing a safe environment and adequate supervision to prevent accidents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. During a medication pass observation, two errors were identified out of 32 opportunities. The first error involved the non-administration of Citracal-D3, a calcium citrate supplement, to a resident as per the physician's order for daily administration at 8:00 a.m. The LPN responsible confirmed that the medication was not administered because it was unavailable. The second error involved the administration of an incorrect dosage of Lisinopril, an angiotensin-converting enzyme inhibitor. The resident was given a 20mg tablet instead of the prescribed 10mg. The LPN acknowledged the mistake and confirmed the correct order was for a 10mg daily dose. The Director of Nursing was informed of these errors and confirmed that medications should be administered as ordered.
Failure to Maintain Personal Hygiene for Residents
Penalty
Summary
The facility failed to provide necessary services for maintaining good personal hygiene for two residents who were unable to perform activities of daily living. Resident #3, who had a history of transient ischemic attack, severe vascular dementia, and a Stage 4 pressure ulcer, was observed with a dirty hand mitt that had a large, dried reddish-brown stain. Despite being notified, the LPN reapplied the dirty mitt. Later, the DON confirmed the mitt was unclean, and upon removal, the resident's hand was found to be crusty and dirty, with jagged and untrimmed fingernails. Resident #37, diagnosed with Parkinson's disease and vascular dementia, was observed with long and jagged toenails. The DON confirmed the need for trimming the toenails. Both cases highlight the facility's failure to adhere to its Nail Management Policy and Procedure, which emphasizes regular care to promote cleanliness and prevent infection and injury.
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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