Willow Wood At Woldenberg Village
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 3701 Behrman Place, New Orleans, Louisiana 70114
- CMS Provider Number
- 195156
- Inspections on file
- 25
- Latest survey
- July 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Willow Wood At Woldenberg Village during CMS and state inspections, most recent first.
The facility did not complete required post-fall evaluations or update care plans with new interventions for two residents after multiple falls, and failed to secure a portable oxygen tank in a resident's room as per policy. Nursing staff confirmed the lack of documentation and adherence to procedures.
Two residents receiving nebulizer treatments did not have their respiratory equipment changed or stored according to facility policy. One resident's nebulizer mask was kept in a plastic bag dated over a month prior, with no documentation of weekly changes, while another resident's nebulizer mask was repeatedly left uncontained on their lap or bedside table. Staff interviews and record reviews confirmed these lapses in following established procedures for respiratory care equipment.
A resident with moderate cognitive impairment was not assessed for self-administration of medications as required by facility policy. The resident was observed with multiple medications at bedside and in the bathroom, and confirmed self-application of a topical cream. Nursing staff and administration acknowledged that no assessment had been completed and that medications should not have been left accessible.
A resident with severe cognitive impairment and a new diagnosis of schizophrenia was not referred for a required PASARR Level II evaluation. Despite the diagnosis and care planning for behavioral issues, there was no documentation that the necessary screening was completed, as confirmed by the Social Service Director.
A resident with hemiplegia and moderate cognitive impairment, identified as at risk for pressure ulcers, was left on a deflated air-loss mattress for over eight hours. Despite the resident reporting air escaping and a low air pressure warning being visible, staff did not physically check the mattress's inflation. The issue was later traced to the CPR function being activated, but the resident remained on the improperly inflated mattress for an extended period, contrary to the care plan and facility policy.
A resident with a PEG tube was not given enteral nutrition at the physician-ordered rate. The feeding pump was set at 60 mL/hr instead of the prescribed 50 mL/hr, a discrepancy confirmed by both an LPN and the ADON. Facility policy requires nurses to confirm the correct rate, but this was not done.
A CNA was observed handling a resident's food with bare hands during meal service, including picking up food from the plate and bedside table, without performing hand hygiene. Facility staff confirmed that this practice was not appropriate and did not follow professional standards for food safety.
A resident with dementia who exhibited aggressive behaviors was told by facility staff that return from a behavioral health hospital would only be allowed if the family provided a personal sitter. Multiple staff communicated this requirement to the resident's representative, who could not afford the service, resulting in the resident being taken home. This action violated facility policy and resident rights regarding personal funds and conditions of continued stay.
A resident was transferred to a behavioral health hospital without the facility providing the required written notification to the resident's representative or the State's LTC Ombudsman. Record review and interviews confirmed that neither party received written notice of the transfer, and the administrator acknowledged the omission.
The facility did not post daily nurse staffing information in a prominent and accessible location as required. Observations confirmed the absence of posted information, and both the administrator and DON stated they were unaware of the requirement, resulting in the information not being made available.
The facility failed to discard insulin pens within 28 days of opening, as required. During an observation, it was found that insulin pens for two residents were available for use despite being expired. An LPN and the DON confirmed that these pens should have been discarded and replaced with new ones.
The facility failed to maintain food safety and sanitation standards, including improper thawing of raw chicken, unsanitary conditions in the walk-in cooler, excessive ice in the freezer, and inadequate monitoring of sanitization levels in dishwashing equipment.
Failure to Complete Post-Fall Evaluations and Secure Oxygen Tanks
Penalty
Summary
The facility failed to complete required evaluations after residents sustained falls, as outlined in their own policy. Specifically, two residents who were identified as high risk for falls experienced multiple falls, but there was no documented evidence that post-fall evaluations were conducted within the required timeframe. Additionally, the care plans for these residents were not revised to include new individualized interventions following each fall, despite repeated incidents. Interviews with nursing staff confirmed the absence of documentation for both the evaluations and care plan updates after the falls occurred. Furthermore, the facility did not ensure that oxygen tanks were properly secured according to policy. Observations revealed that a portable oxygen tank was found free standing on the floor in a resident's room on two separate occasions, rather than being strapped to a cylinder stand or stored in the designated cage. Staff interviews confirmed that the oxygen tanks should have been secured as per facility policy, but this was not done.
Failure to Change and Store Nebulizer Equipment per Facility Policy
Penalty
Summary
The facility failed to adhere to its own policy regarding the maintenance and storage of nebulizer equipment for two residents requiring respiratory care. For one resident with physician orders for Ipratropium-Albuterol nebulizer treatments as needed for wheezing, observations revealed that the nebulizer mask was stored in a plastic bag dated over a month prior, with no documented evidence that the tubing and mouthpiece had been changed weekly as required by facility policy. Interviews with nursing staff and review of the electronic Medication Administration Record (eMAR) confirmed that there was no documentation of the equipment being changed since the date on the bag. Another resident, also with physician orders for Ipratropium-Albuterol nebulizer treatments, was observed multiple times with the nebulizer mask left uncontained, either on the resident's lap or on the bedside table, rather than being stored in a plastic bag as required. Nursing staff confirmed during interviews that the nebulizer mask should have been stored in a plastic bag when not in use, in accordance with facility policy. These deficiencies were identified through direct observation, interviews with staff, and review of medical records, which consistently showed a lack of compliance with the facility's established procedures for cleaning, changing, and storing nebulizer equipment. The failure to follow these procedures was confirmed by both the LPN Supervisor and the Infection Preventionist, who acknowledged the absence of documentation and proper storage practices for the residents' respiratory care equipment.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required by its own policy. The policy states that residents should be assessed for self-administration of medications upon admission, quarterly, annually, and with any significant change in condition. Review of the resident's record showed no documented evidence of such an assessment, despite the resident having a moderate cognitive impairment as indicated by a Brief Interview for Mental Status score of 11 on the most recent Minimum Data Set. Observations revealed that the resident had access to multiple medications at her bedside and in her bathroom, including an opened tube of Cloderm 0.1% cream, a bottle of pain relief roll-on with lidocaine hydrochloride 4%, and several tablets in medication cups. The resident confirmed self-application of the cream. Interviews with nursing staff and administration confirmed that the resident had not been assessed for self-administration and that medications should not have been left at the bedside or in the bathroom.
Failure to Complete PASARR Level II Evaluation After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of schizophrenia was referred for a required Preadmission Screening and Resident Review (PASARR) Level II evaluation. The resident was admitted in 2010 and was diagnosed with schizophrenia in 2018. Despite this new diagnosis, there was no documented evidence in the clinical or medical record that a Level II PASARR evaluation was completed following the diagnosis. The resident's annual assessment indicated severe cognitive impairment and an active diagnosis of schizophrenia without dementia, and a care plan was developed for behavioral alterations related to psychosis, including placement on the Memory Care Unit. During an interview, the Social Service Director confirmed that the required Level II PASARR evaluation had not been completed after the new diagnosis.
Failure to Maintain Inflated Pressure Reducing Mattress for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for skin breakdown was left on a deflated air-loss pressure reducing mattress for over eight hours. The facility's policy required the use of a specialized mattress for residents at risk of pressure ulcers, and the resident's care plan included an intervention for a pressure reduction mattress. Observations revealed that the mattress had a low air pressure warning light activated, and the bed frame was palpable when pressure was applied, indicating the mattress was not properly inflated. The resident reported hearing air escaping from the mattress and informed staff, who responded only by confirming the mattress was plugged in, without physically checking the mattress's inflation. Further investigation found that a nurse on the night shift observed the low air pressure warning and later determined that the CPR function on the mattress had been activated, causing it to deflate. The Assistant Director of Nursing confirmed that the resident remained on the deflated mattress for an extended period. The resident had a history of hemiplegia, moderate cognitive impairment, and was at risk for pressure ulcers due to incontinence, debility, and comorbidities. The failure to ensure the mattress was properly inflated and to respond appropriately to the resident's report led to the deficiency.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube was not administered enteral nutrition as ordered by the physician. The resident's medical record indicated an order for Glucerna 1.2 Cal to be infused at 50 mL/hour over 22 hours. However, during observation, the resident's feeding pump was found set at 60 mL/hour. This discrepancy was confirmed by both an LPN and the Assistant Director of Nursing, who acknowledged that the pump should have been set to the ordered rate of 50 mL/hour. The facility's policy requires nurses to confirm the administration method and volume/rate of enteral feedings, but this was not followed in this instance.
Failure to Maintain Sanitary Food Handling During Meal Service
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to serve food in a sanitary manner to a resident during lunch service. The CNA was observed delivering a lunch tray to the resident's room, removing the insulated cover from the plate, and handling the resident's food with bare hands. Specifically, the CNA repositioned the resident's feet, picked up a chicken tender from the plate and placed it in the resident's hand, and later picked up the same chicken tender from the bedside table and returned it to the plate, all without performing hand hygiene at any point during the process. Interviews with facility staff, including a licensed practical nurse (LPN) supervisor, the infection preventionist, and the assistant director of nursing, confirmed that staff should not touch residents' food with bare hands during meal service. The CNA also acknowledged that she should not have touched the food with bare hands. These actions were not in accordance with the 2022 FDA Food Code, which requires the use of suitable utensils or gloves to prevent cross-contamination of ready-to-eat food.
Resident Required to Provide Personal Sitter as Condition of Return
Penalty
Summary
The facility failed to ensure that a resident was not required to provide a personal sitter as a condition of continued stay. According to the facility's own Resident Rights policy, non-covered special care services such as privately hired aides may only be charged to residents if requested by the resident, and the facility must not require such services as a condition of admission or continued stay. In this case, a resident with a diagnosis of unspecified dementia was admitted to the dementia unit and subsequently became verbally and physically aggressive towards staff, leading to a transfer to a behavioral health hospital under a Psychiatric Emergency Certificate. Following the transfer, multiple staff members, including the ADON, DON, and Social Worker, communicated to the resident's representative that the resident could only return to the facility if the family supplied a personal sitter to monitor behaviors. This requirement was reiterated in emails and interviews, and the behavioral health hospital was also informed of this condition. The resident's representative stated she could not afford to pay for a personal sitter, resulting in the resident being taken home instead of returning to the facility. The facility's actions directly contradicted their policy and regulatory requirements regarding resident rights and the use of personal funds for services covered by Medicare or Medicaid.
Failure to Provide Required Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to both a resident's representative and the State's Long-Term Care Ombudsman regarding the resident's transfer to a behavioral health hospital. Review of the electronic medical record and clinical documentation for the resident showed no evidence that such written notices were issued at the time of transfer. Interviews with the assigned Ombudsman and the resident's representative confirmed that neither received written notification of the transfer. The facility administrator also acknowledged that the required written notices were not provided to the resident's representative or the Ombudsman at the time of the transfer.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent and readily accessible location as required. Observations conducted in the facility's hallways and public areas revealed that the required staffing information was not displayed. Additionally, the facility was unable to provide any documented evidence that the daily nurse staffing information had been posted. During interviews, both the administrator and the director of nursing stated they were unaware of the requirement to post this information, and confirmed that it had not been done due to this lack of awareness.
Expired Insulin Pens Not Discarded
Penalty
Summary
The facility failed to ensure that insulin medications were discarded within 28 days of being opened, as required by professional principles. During an observation of medication storage, it was found that insulin pens for two residents were available for use despite being past the 28-day expiration period. Specifically, Resident #42's Insulin Aspart Pen and Resident #97's Lantus Solostar Pen were both opened beyond the acceptable timeframe and had not been discarded. Interviews with the LPN and the Director of Nursing confirmed that these insulin pens should have been discarded and replaced with new ones, as they were expired and should not have been available for use.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas. Raw chicken was observed being thawed improperly in a metal container submerged in water, which was confirmed by the chef and cook as not following the correct procedure of thawing under running water. Additionally, the walk-in cooler was found to be unsanitary, with a foul odor and various unknown substances pooled on the floor and along the baseboard tiles, which the chef acknowledged needed cleaning. The walk-in freezer was also found to have a thick layer of ice accumulation on its floor, walls, shelves, ceiling, and fan, which was confirmed by the chef as inappropriate. Furthermore, the facility did not document the water temperature and sanitization levels of the 3-compartment sink and dishwasher as required. The sanitization level of the dishwasher was tested and found to be below the required chlorine concentration, which was confirmed by the chef.
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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