Village Health Care At The Glen
Inspection history, citations, penalties and survey trends for this long-term care facility in Shreveport, Louisiana.
- Location
- 403 E. Flournoy Lucas, Shreveport, Louisiana 71115
- CMS Provider Number
- 195533
- Inspections on file
- 26
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Village Health Care At The Glen during CMS and state inspections, most recent first.
A cognitively impaired resident with hemiplegia, Alzheimer’s disease, and dependence for transfers was subjected to physical abuse and unsafe transfer techniques by a CNA. Video showed the CNA entering without greeting, ignoring the resident’s request about food, repeatedly yelling at the resident to “Get up,” and forcefully pulling the resident up by the left upper arm without a gait belt, despite the resident grimacing and saying “Wait.” The CNA roughly manipulated the resident’s arm, rammed the wheelchair into the bed, lifted the resident by the underarms, and dropped the resident into an unlocked wheelchair, after which the resident cried out in pain and rubbed her left arm. Skin assessments later documented multiple reddish-purple areas on the back of the resident’s left upper arm resembling fingerprints. The Administrator and DON confirmed that the CNA’s actions constituted physical abuse and caused psychosocial harm, with the resident appearing frightened during the incident.
A resident with hemiplegia, Alzheimer's disease, muscle weakness, and other coordination deficits had a care plan identifying them as a fall risk, with an intervention requiring fall mats on each side of the bed when in bed. On multiple observations, the resident was found in bed or in their room without fall mats in place, and both a CNA and the ADON confirmed that the room lacked the care-planned fall mats despite the documented intervention.
A resident with dementia, impaired balance and gait, and a history of multiple falls, assessed as high risk for falls and requiring partial assist for transfers and ambulation, was cared for in a room where the floor surface was repeatedly observed to be dry but shiny, slippery, and lacking traction along the entry, walkway, and around the bed and recliner. Staff including a CNA, housekeeping, an LPN, the ADON, the Administrator, and the housekeeping supervisor all acknowledged the floor was slippery and posed a fall risk after it was mopped with the facility’s standard cleaning solution, and the resident reported the floor sometimes felt slippery and at other times like glue, causing shoes to stick. Despite these observations and the resident’s documented fall risk and history of falls in the room and bathroom, the environment was not maintained free of this accident hazard.
A facility failed to evaluate a resident's fall risk and implement necessary interventions, leading to multiple unwitnessed falls. Despite having a high fall risk score, the resident's Baseline Care Plan lacked specific interventions for fall prevention. Interviews with facility staff confirmed that a fall risk assessment should have been conducted upon admission and interventions included in the care plan.
Two residents did not receive medications according to physician's orders or within the facility's liberalized time blocks. One resident's medications were administered late, between 10:45 a.m. and 10:55 a.m., while another's were given at 11:17 a.m. An LPN admitted to not adhering to scheduled times, indicating a failure to follow both physician's orders and facility policy.
A facility failed to implement fall prevention measures for a resident with severe cognitive impairment and a high risk of falls. Observations revealed only one fall mat was in place, contrary to physician orders for two mats. The resident's medical history includes Alzheimer's, impaired mobility, and a history of multiple falls.
Two residents with severe cognitive impairments were found with bed rails raised without a physician's order, risk assessment, or informed consent. Observations confirmed the continuous use of bed rails, and the facility's administrator acknowledged the lack of proper assessments and documentation.
A resident with severe dementia was improperly restrained with a self-releasing seatbelt in a wheelchair without written consent or documentation, contrary to facility policy. Staff interviews revealed a lack of awareness about the resident's ability to remove the seatbelt, and the seatbelt was not perceived as a restraint by the Administrator.
The facility failed to provide appropriate pain management for a resident after a fall, as no initial pain assessment was completed despite multiple injuries. The resident was later diagnosed with a displaced fracture causing significant pain.
The facility failed to comprehensively assess a resident using the CMS-specified Resident Assessment Instrument after the resident was hospitalized following a cerebral infarction and a right femoral head fracture. Despite the significant change in condition, the required significant change MDS was not completed.
The facility failed to ensure that resident assessments were transmitted to the State within the required 7-day timeframe for 10 residents. Multiple instances were found where assessments were either not completed, not submitted, or not accepted within the required timeframe. The Medicare Case Manager acknowledged these failures during an interview, confirming the facility's non-compliance with regulatory requirements.
The facility failed to maintain sanitary conditions in the kitchen, with issues including unlabeled and frostbitten meat, opened and unlabeled jars, unclean equipment, and grease and food residue on various surfaces. Staff confirmed these lapses, which affected food safety for 12 residents.
Physical abuse and unsafe transfer of a cognitively impaired resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse and psychosocial harm by a CNA. The resident, who resided on a locked memory care unit, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer’s disease, and muscle weakness. A quarterly MDS showed a BIMS score of 0, indicating severely impaired cognition, and the resident was dependent on staff for bed-to-chair transfers. The resident’s care plan identified her as a fall risk and required the use of a gait belt for all transfers with assistance from one staff member. On the morning of the incident, surveillance video with audio captured the events in the resident’s room. The video showed housekeeping staff initially conversing with the resident, who was seated on the side of the bed, smiling, laughing, and verbally interacting appropriately. After housekeeping exited, the CNA entered the room carrying linens and clothing, did not greet or acknowledge the resident, and failed to respond when the resident asked about getting something to eat. The CNA then approached the resident and, without using a gait belt, attempted to pull the resident up by her left arm. The CNA yelled “Get up!” and forcefully gripped and pulled the resident’s left upper arm multiple times in an upward motion. The resident was observed grimacing, saying “Wait,” and being unable to stand, while the CNA continued to hold and manipulate the resident’s left upper arm, swinging her back into the bed when she could not maintain a standing position. The video further showed the CNA dropping linens and clothing on the bed, forcefully tossing the resident’s shoes to the floor, and ramming the resident’s wheelchair into the wooden footboard, causing the bed to shake. When the CNA brought the wheelchair to the resident, the resident recoiled, appeared frightened, and verbally stated she could get up if the CNA did not mind, but the CNA did not respond. The CNA placed the unlocked wheelchair in front of the resident, lifted the resident by her underarms without a gait belt, and dropped her into the wheelchair, with an audible impact and the resident exclaiming “Ow!” The resident then rubbed her left arm, moaned, and appeared to express pain. The CNA proceeded to pull the resident backward in the wheelchair, again striking the footboard, and then rolled the resident into an unlit bathroom. Throughout the interaction, the CNA repeatedly yelled at the resident by her first name to “Get up,” handled her roughly, and failed to use safe transfer techniques. Subsequent documentation and interviews linked physical findings to this event. A late entry progress note by the Administrator described a nickel-sized irregular bright purple purpura on the lateral upper left arm near the antecubital space, and a later note documented multiple areas of bright purple purpura on the posterior left upper arm. A weekly skin review by an LPN on 01/11/2026 recorded four small reddish-purple areas on the back of the left upper arm just above the elbow, which the LPN described as looking like fingerprints; the DON reported these could have been from the CNA’s fingerprints. The Administrator and DON both confirmed, based on review of the video, that the CNA physically abused the resident by yelling, grabbing, lifting, twisting, and roughly transferring her without a gait belt, and that the resident appeared frightened during the event. The Administrator further stated that a reasonable person subjected to this physical abuse and verbal aggression would have experienced physical abuse and psychosocial harm, including dehumanization and humiliation.
Failure to Implement Care-Planned Fall Mats for a High Fall-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan intervention for a resident identified as a fall risk. The resident, admitted on 07/03/2025, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness. The resident’s comprehensive care plan documented, as of 10/22/2025, that fall mats were to be placed on each side of the bed when the resident was in bed. However, observations on 03/09/2026 at 8:27 a.m. and again at 2:20 p.m. showed the resident in bed or in the room without fall mats in place on either side of the bed. During interview at 2:20 p.m., a CNA confirmed that the resident’s room did not have fall mats in place. At 3:05 p.m., the ADON acknowledged that the care plan included the intervention of a fall mat, and a subsequent observation at 3:10 p.m. with the ADON again confirmed that no fall mats were present in the resident’s room despite the care plan requirement. This deficiency centers on the discrepancy between the documented fall-prevention intervention in the resident’s care plan and the lack of implementation of that intervention as evidenced by multiple observations and staff confirmations on the same day.
Failure to Maintain Non-Skid Flooring for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s room environment free from accident hazards by not ensuring the floor surface provided adequate non-skid traction. The facility’s own Falls and Fall Risk, Managing policy identified environmental factors such as wet floors as contributors to fall risk and required staff to identify interventions based on resident-specific risks. Resident #3, admitted with a displaced mid-cervical fracture of the left femur (subsequent encounter) and unspecified dementia, had a BIMS score of 10 indicating moderately impaired cognition and required partial staff assistance for transfers and ambulation. The resident’s care plan documented a history of falls related to impaired balance and gait, with an intervention for frequent observation and supervised placement when out of bed. The medical record showed multiple falls over several dates, and a fall risk assessment identified the resident as high risk for falls. Surveyor observations on multiple occasions found Resident #3’s room floor to be dry but shiny, slippery, and with little traction along the entry, walkway, and around the bed and recliner. A CNA, housekeeping staff, an LPN, the ADON, the Administrator, and the Housekeeping Supervisor each observed or acknowledged that the floor in this resident’s room was slippery, shiny, and posed a fall risk. The housekeeping staff reported mopping the floor with the facility’s standard floor cleaning solution, and the Administrator stated that the floors had never been waxed and were cleaned with house cleaner, while acknowledging the condition of the floor as a fall hazard. The resident reported that at times the floor felt slippery and at other times felt like glue, causing shoes to stick. Despite the resident’s high fall risk, history of falls in the room and bathroom, and multiple staff acknowledgments of the slippery condition, the floor surface remained in a state that did not provide adequate traction, resulting in an environmental accident hazard for this resident.
Failure to Address Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to ensure a resident's environment was as free of accident hazards as possible by not evaluating the resident's fall risk and implementing necessary interventions. The resident, who had multiple diagnoses including coronary artery disease, hypertension, and major depressive disorder, was admitted without a fall risk assessment being conducted. A fall risk assessment was eventually performed on 02/10/2025, revealing a high risk for falls with a score of 23, but this was after the resident had already experienced multiple unwitnessed falls on 02/01/2025, 02/05/2025, 02/09/2025, and 02/10/2025. The resident's Baseline Care Plan, initiated on 01/31/2025, identified safety concerns such as fall risk but did not include any specific interventions to address this risk. Interviews with the Director of Nursing, Assistant Director of Nursing, and the Administrator confirmed that a fall risk assessment should have been conducted upon admission and that interventions should have been included in the care plan to mitigate the resident's fall risk. The lack of these assessments and interventions contributed to the deficiency identified by the surveyors.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that two residents received medications in accordance with physician's orders and within the established liberalized medication time blocks. For one resident, multiple medications were administered outside the designated time frame of 7:00 a.m. to 10:30 a.m., with administration times recorded between 10:45 a.m. and 10:55 a.m. These medications included folic acid, vitamin C, ferrous sulfate, and several others, all of which were scheduled for earlier administration. The failure to adhere to the prescribed schedule was documented in the Medication Administration Record (MAR). Another resident's medications, which were ordered to be administered at 7:00 a.m., were not given until 11:17 a.m. The medications included Lexapro, Bupropion, Hydralazine, and others. During an interview, an LPN acknowledged that there was no set time for medication administration and admitted to not administering the morning medications on time. This indicates a deviation from both the physician's orders and the facility's policy on liberalized medication administration times.
Failure to Implement Fall Prevention Measures for a High-Risk Resident
Penalty
Summary
The facility failed to ensure that the environment for one of the sampled residents, identified as Resident #3, was as free from accident hazards as possible. Specifically, the facility did not have the required fall mats in place as ordered by the physician to prevent injuries. Observations on two separate occasions revealed that only one fall mat was positioned on the right side of the resident's bed, whereas the physician's orders dated 08/31/2024 specified that two fall mats should be applied, one on each side of the bed, when the resident is in bed. This discrepancy was confirmed during an interview with a Certified Nurse Assistant (CNA), who acknowledged that there should have been two fall mats in place. Resident #3 has a medical history that includes Alzheimer's disease, impaired balance, impaired mobility, muscle weakness, essential hypertension, and an unspecified extrapyramidal and movement disorder. The resident's fall risk assessment indicated a high risk for falls, with a total score of 18, and a history of three or more falls. The Minimum Data Set (MDS) assessment showed severe cognitive impairment with a BIMS score of 3, and the resident requires one-person physical assistance with bed mobility, transfers, eating, and toilet use. The care plan for Resident #3 included monitoring and interventions to reduce the potential for self-injury from falls, with approaches that involve supervision and verbal reminders to control risk factors.
Failure to Ensure Proper Use and Documentation for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for two residents, leading to a deficiency in compliance with safety protocols. Resident #1, diagnosed with Parkinson's disease, dementia, schizoaffective disorder, and other conditions, was found with bed rails raised without a physician's order, risk assessment for entrapment, or informed consent. Observations over two days confirmed the continuous use of bed rails without the necessary documentation or assessments. Similarly, Resident #2, with diagnoses including spondylosis, dementia, and muscle weakness, was also observed with bed rails raised without the required physician's order, risk assessment, or informed consent. Interviews with the facility's administrator confirmed the lack of proper assessments and documentation for both residents, acknowledging the oversight in following the necessary procedures for bed rail use.
Improper Use of Physical Restraint Without Consent
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints that were not required to treat medical symptoms. The resident, who was diagnosed with severe unspecified dementia with mood and behavioral disturbances and muscle weakness, was observed using a self-releasing seatbelt while seated in a high-back wheelchair. The facility's policy requires that any physical restraint must be easily removable by the resident in the same manner it was applied by staff, and consent must be obtained. However, the resident was unable to remove the seatbelt on command due to cognitive impairments, and no written consent for the use of the seatbelt was obtained. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's ability to remove the seatbelt. An LPN was unsure if the resident could remove the seatbelt and observed that the resident did not understand the request to do so. The Director of Nursing acknowledged the absence of written consent and documentation for the seatbelt's use, and the Administrator admitted that consent was not obtained because the seatbelt was not perceived as a restraint. This oversight led to the improper use of a restraint without the necessary consent and documentation, contrary to the facility's policy.
Failure to Provide Pain Management After Resident Fall
Penalty
Summary
The facility failed to ensure pain management was provided to a resident who required such services after a fall/injury. Specifically, the facility did not complete an initial pain assessment for the resident following the incident. The resident was found on the floor with multiple injuries, including a knot on the back of the head, cuts on the thumb and knee, and a skin tear on the leg. Despite these injuries, there was no documentation of a pain assessment in the initial ID notes, the Incident Report, or the Neurological Evaluation Flow Sheet. The resident was later diagnosed with a displaced fracture of the left femoral neck, which caused significant pain upon manipulation of the left lower extremity, as noted by the Nurse Practitioner the following day. Interviews with the Director of Nursing and an LPN confirmed that a pain assessment should have been completed but was not. The Director of Nursing acknowledged the absence of a pain assessment in the facility's computer system and the Incident Report. The LPN explained that standard procedure involves documenting a head-to-toe assessment and asking residents to rate their pain level, or observing their response if they are unable to communicate. However, the review of the ID notes confirmed that no such assessment was documented for this resident after the fall.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed using the CMS-specified Resident Assessment Instrument after experiencing a significant change in condition. Resident #82 was hospitalized following a cerebral infarction and a right femoral head fracture. The resident's diagnosis included hemiplegia following a cerebral infarction affecting the left non-dominant side and a right femoral head fracture. On the date of the incident, the resident was found lying supine on the floor with no movement in her right lower extremity and tremors on the left side of her body. The resident was assessed by a nurse and assisted into her wheelchair by three staff members before being transferred to the emergency room for evaluation. Hospital records confirmed the diagnosis of an acute ischemic left MCA stroke, cytotoxic cerebral edema, and a displaced right femoral head fracture. Despite the significant change in Resident #82's condition, a review of the Minimum Data Set (MDS) for the dates following the incident revealed that a significant change assessment was not completed. During interviews, the Medicare Case Manager confirmed that she did not complete the required significant change MDS, and the Administrator verified that such an assessment should have been completed. This oversight indicates a failure to follow CMS guidelines for assessing residents after a significant change in their condition.
Failure to Transmit Resident Assessments Timely
Penalty
Summary
The facility failed to ensure that resident assessments were transmitted to the State within the required 7-day timeframe for 10 residents out of a total of 35 sampled residents. The review of the Minimum Data Set (MDS) assessments for these residents revealed multiple instances where assessments were either not completed, not submitted, or not accepted within the required timeframe. For example, Resident #3 had an Other State Assessment MDS completed on 02/15/2024 but was only submitted and accepted on 03/21/2024. Similarly, Resident #41 had a Quarterly MDS that was not completed, not submitted, and not accepted. These delays and failures in submission were consistent across all 10 residents reviewed. During an interview on 04/11/2024, the Medicare Case Manager acknowledged that the MDS assessments for the 10 residents had not been completed and transmitted to CMS within the required timeframe. This acknowledgment confirms the facility's failure to adhere to the regulatory requirements for timely submission of resident assessments, which is crucial for maintaining accurate and up-to-date resident care records. The deficiencies were identified through a combination of record reviews and interviews, highlighting a systemic issue in the facility's assessment and submission processes.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, potentially affecting 12 residents who received trays from the main kitchen. Observations revealed several deficiencies: meat with a frostbitten appearance inside an unlabeled plastic bag in the freezer, opened and unlabeled jars of jalapenos, tartar sauce, pepperoncini, and lime juice in the walk-in refrigerator, and a stand mixer with yellow and white food residue. Additionally, grease and food residue were noted on the outside of both fryers, the floor between the stove and fryers, and the pipes and wall behind the fryer and stove. The walk-in refrigerator also had food and debris on the floor. Interviews with kitchen staff confirmed these observations. The cook acknowledged that the meat should have been removed before going bad and that opened, unlabeled items should have been labeled with an opened date. The chef confirmed that the kitchen and equipment should be cleaned daily by the morning and evening staff, and that the meat and opened items should have been properly managed. These lapses in following the facility's Basic Standards-Food Services-Health Care Policy led to the identified deficiencies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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