Tri-community Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Palmetto, Louisiana.
- Location
- 7014 Hwy 71, Palmetto, Louisiana 71358
- CMS Provider Number
- 195552
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Tri-community Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection control program by not analyzing repeated PEG infections and repeated UTIs and by not following its system for identifying potential infections. An Infection Preventionist stated she did not determine the cause of the repeated infections or develop a plan to prevent future infections, and the DON confirmed the infections should have been analyzed monthly. For one resident with a urinary catheter and multiple medical diagnoses, cloudy, foul-smelling urine led to a U/A C&S order, but the specimen results were not followed up in a timely manner and nursing documentation showed no ongoing follow-up until the Infection Preventionist later located the lab results.
Failure to Provide Quarterly Personal Funds Statements: A resident with a personal funds account stated he had not received quarterly statements for several months. The S10PFS, who was responsible for providing the statements, confirmed the resident did not receive them while she was out of the facility for several months, despite the facility policy requiring quarterly statements and access upon request.
Two residents had quarterly MDS assessments coded as receiving anticoagulants even though their MAR/physician orders showed no anticoagulant orders. During an interview, MDS staff reviewed the EHR, clarified that Plavix is an antiplatelet medication, and confirmed both MDSs were coded inaccurately.
Failure to provide nail hygiene during ADL care: Three residents with severely impaired cognition and significant assistance needs had dirty fingernails with visible buildup under the nails. The facility policy required routine nail cleaning during ADL care, but observations and staff interviews confirmed the nails were not clean for residents with dementia, diabetes, hemiplegia, aphasia, and other conditions requiring assistance with personal hygiene.
Delayed Urine Specimen Transport and Lab Processing: A resident with confusion and incontinence had a UA/C&S ordered, but a urine specimen was collected and left in the specimen refrigerator, then discarded after being held too long before a new sample was sent to the lab. Interviews confirmed the facility had no written policy or process for timely urine specimen collection, transport, or lab follow-up, and the results were not received until the resident later went to the hospital for a swollen knee.
Medications Left Unlocked on Top of Medication Cart An LPN was observed leaving blister packets of Baclofen and Hydralazine on top of a med cart in the hall while entering a resident's room to administer meds. The cart was not in the LPN's direct view, and the LPN later confirmed the meds should not have been left on top of the cart and should have been locked in the med cart.
The facility failed to submit accurate PBJ staffing data, resulting in a one-star staffing rating and low weekend staffing. The Administrator misclassified two LPNs, leading to incorrect payroll information submission.
A resident at high risk for falls was not adequately supervised, as their bed alarm was repeatedly found non-functional and improperly placed. Despite care plans and orders requiring frequent monitoring and the use of a bed alarm, staff failed to ensure the alarm was operational, posing a risk of accidents.
A facility failed to provide proper catheter care for a resident with an indwelling urinary catheter. The resident's urinary drainage bag was observed lying on the floor beneath her bed, contrary to the facility's policy, which requires the bag to be clipped to the bed below the bladder. A CNA confirmed the improper placement, and an LPN/Infection Preventionist reiterated the correct procedure.
Infection Control Program Failed to Track and Investigate Repeated Infections
Penalty
Summary
The facility failed to maintain an effective infection control program by not analyzing the cause of repeated facility-acquired infections and by not following its system for identifying potential infections. The facility policy stated that the Infection Preventionist was responsible for oversight of surveillance, investigations, documentation of findings, and corrective actions, and that surveillance was to be used for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. A review of the monthly tracking and trending binder for December 2025 through February 2026 showed a resident with repeated PEG infections and two residents with repeated UTIs. During interview, the Infection Preventionist stated she did not determine the cause of the repeated infections or develop a plan for preventing future infections. The DON confirmed that the repeated PEG infection and repeated UTIs should have been analyzed monthly to determine the causes and develop a plan to prevent future infections. For one resident with diagnoses including cerebrovascular disease, aphasia, dysphagia, urinary retention, urinary catheter, incomplete bladder emptying, acute hepatitis C, and benign prostatic hyperplasia, a physician ordered a U/A with C&S after cloudy, foul-smelling urine was noted. The urine culture later showed Pseudomonas aeruginosa and Providencia stuartii, but the results were not obtained by the facility until weeks later. Nursing documentation did not show follow-up on the urine test results until the Infection Preventionist located them, and the nurse who collected the specimen stated she did not follow up with the nurse or the Infection Preventionist about the results. The Infection Preventionist stated she had not been made aware of the cloudy, foul-smelling urine or the lab order, and the DON stated staff were supposed to notify her of the order and collection so she could follow up with the lab in a timely manner.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements for Resident #12, who had a personal funds account deposited with the nursing home. During interview, Resident #12 stated he had not received a quarterly statement for several months. Review of the facility’s Resident Personal Funds policy showed that the individual financial record must be available to the resident through quarterly statements and upon request. The S10PFS stated she was responsible for providing quarterly personal funds statements to residents with personal funds accounts and confirmed that she had been out of the facility from January 2025 to September 2025 and that Resident #12 did not receive quarterly statements during that time.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 2 of 25 sampled residents, Resident #32 and Resident #44. Review of each resident’s quarterly MDS showed both were coded as receiving anticoagulants, but review of their physician orders for March 2026 found no anticoagulant orders for either resident. During an interview on 03/24/2026 at 8:50 a.m., S4MDSIP and S5MDS reviewed the electronic clinical record and initially discussed Plavix as the anticoagulant; S5MDS then corrected that Plavix is an antiplatelet medication, and both staff confirmed that neither resident was actually on an anticoagulant and that the MDS entries were coded inaccurately.
Failure to Provide Nail Hygiene During ADL Care
Penalty
Summary
The facility failed to ensure residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. The facility policy titled, Nail Care, stated that routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis, including gently cleaning underneath nails with an orange stick. However, observations and interviews showed that three residents with significant cognitive and functional impairment had dirty fingernails with visible buildup under or beneath the nails. Resident #13 had vascular dementia, delusional disorder, type 2 diabetes mellitus, and anxiety, with severely impaired cognition and partial/moderate assist needed for personal hygiene. An observation showed dark substance under the fingernails on both hands. Resident #15 had dementia with agitation, major depressive disorder, and cognitive communication deficit, with severely impaired cognition and dependent x2 assist for personal hygiene. Observations showed a black substance under the fingernails on the left hand, and staff confirmed the nails were dirty. Resident #35 had cerebral infarction, hemiplegia and hemiparesis, aphasia, type 2 diabetes mellitus, and Parkinsonism, with severely impaired cognition and substantial/maximal assist needed for personal hygiene. An observation showed a thick build-up of grime under the fingernails on both hands, and staff confirmed the nails were dirty and needed cleaning.
Delayed Urine Specimen Transport and Lab Processing
Penalty
Summary
The facility failed to have a policy or process in place to ensure that collected urine specimens were sent to the lab in a timely manner for Resident #11, who was admitted with absence epileptic syndrome, recurrent major depressive disorder, and iron deficiency anemia and was always incontinent of urine and bowel. When the resident showed signs and symptoms of confusion, a nurse obtained an order for UA and C&S. An initial attempt to collect urine was unsuccessful because the resident was incontinent, and when urine was later obtained it was placed in the specimen refrigerator and the supervisor was notified. The urine specimen collected on 11/21/2025 was discarded on 11/24/2025 because it had been obtained over 24 hours earlier, and a new sample was then collected and sent to the lab. The urinalysis from the later specimen showed cloudy urine, elevated WBCs, and moderate bacteria, and the microbiology report later identified greater than 100,000 cfu/ml Escherichia coli. The facility did not receive the urinalysis results until the resident was sent to the hospital for a swollen knee. Interviews confirmed the facility had no written policy addressing urine collection, transportation to the lab, or timely receipt of results, and staff stated there was no process in place to ensure specimens were removed from the refrigerator and sent out promptly.
Medications Left Unlocked on Top of Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals remained stored in locked compartments when medication was left unattended on top of a medication cart during a medication pass. The facility's Medication Storage policy, which was not dated, stated that all drugs and biologicals are to be stored in locked compartments such as medication carts, cabinets, drawers, refrigerators, or medication rooms, and that during a medication pass medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. On 03/24/2026 at 11:08 a.m., an LPN was observed leaving blister packets of Baclofen and Hydralazine on top of a medication cart in the hall next to Resident #26's room, then entering the resident's room to administer medications. The cart was not in the LPN's direct view, and upon exiting the room, the LPN observed the two blister packets still on top of the cart and confirmed they should not have been left there and should have been locked in the medication cart.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing to the Centers for Medicare & Medicaid Services (CMS) as required. During a review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year 2024, Quarter 1, it was found that the facility had a one-star staffing rating and excessively low weekend staffing, with the latter metric being suppressed for this facility and quarter. Additionally, the facility failed to maintain licensed nursing coverage 24 hours a day. An interview with the Administrator (S1ADM) revealed that she had incorrectly coded two licensed practical nurses as regular staff members instead of as licensed practical nurses providing direct care to residents, leading to the submission of inaccurate payroll information to PBJ.
Failure to Monitor and Maintain Bed Alarms for High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise and monitor the use of assistive devices, specifically bed alarms, for a resident identified as being at high risk for falls. The resident, who had a history of conditions such as Bipolar Disorder, Major Depression, Seizures, Paralytic Syndrome, Anoxic Brain Damage, Cerebral Vascular Disease, and Hemiplegia affecting the left side, was observed multiple times with a non-functioning bed alarm. Despite the resident's care plan and physician's orders requiring monitoring for falls every half hour and the use of a bed alarm while in bed, the alarm was found to be improperly placed and not operational on several occasions. Observations revealed that the bed alarm pad was either not under the resident's torso or the alarm monitor was not functioning due to dead batteries. Staff members, including CNAs and LPNs, confirmed that it was their responsibility to ensure the alarm was correctly placed and operational. However, repeated observations showed that the alarm was not alarming when the resident moved, indicating a failure in monitoring and supervision. This lack of proper supervision and monitoring of the assistive device posed a risk of accidents for the resident.
Improper Placement of Urinary Drainage Bag
Penalty
Summary
The facility failed to provide appropriate and sufficient services, treatment, and care according to standards of professional practice for a resident with an indwelling urinary catheter. The deficiency was identified during a review of the facility's policy and through observations and interviews. The facility's policy, last reviewed on 12/31/2024, mandates that residents with indwelling catheters receive appropriate care while maintaining dignity and privacy. However, during observations on 02/24/2025, it was noted that the urinary drainage bag of a resident was lying on the floor beneath her bed, which is contrary to the facility's policy. The resident in question was admitted with diagnoses including type 2 diabetes mellitus, anxiety disorder, and urinary retention, and was coded for an indwelling catheter in her quarterly MDS. Despite the policy requiring that drainage bags be clipped to the bed below the resident's bladder, the bag was observed on the floor on two separate occasions. A CNA confirmed the improper placement of the drainage bag and acknowledged that it should have been clipped to the bed. An LPN/Infection Preventionist also stated that proper catheter care involves hanging the drainage bag on the bed or wheelchair with a privacy covering, not on the floor.
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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