Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Consolata Rehab And Wellness Center On The Teche during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection prevention program by not tracking all pathogen data on monthly surveillance maps and by not ensuring staff used required PPE during high-contact care. Two residents on enhanced barrier precautions, including one with metabolic encephalopathy, gastrostomy, and ulcers and another with PVD, atherosclerosis, and a Stage IV pressure ulcer, were observed receiving brief changes and linen care without gowns, and the DON and infection control nurse confirmed the surveillance and PPE lapses.
Food was not prepared as directed and spoiled milk was served to residents. A cook made mashed potatoes without following the recipe, adding milk, salt, and onion powder instead of using the prescribed ingredients and instructions. Two residents were served milk that smelled and tasted sour; one resident had an unfinished glass confirmed spoiled, and another cognitively intact resident reported sour milk on two mornings, with staff later confirming the odor.
Kitchen sanitation, labeling, and milk service failures were identified when maintenance staff entered the kitchen without hair or beard restraints, refrigerated cheese was found without an open date, and residents reported spoiled milk on breakfast trays. Surveyors confirmed milk in both a gallon and a carton smelled and tasted spoiled, and a cook used sour milk to prepare mashed potatoes while the DON/ADM stated the remaining milk would still be served because it had not reached the use-by date.
Failure to maintain privacy during peri-care: Two CNAs provided peri-care to two roommates while the room door was open, the privacy curtain was not drawn, and the window blinds remained up. As a result, each resident’s genitalia was exposed during care. One resident had severe cognitive impairment and was dependent for personal hygiene, and the other had severe memory/thinking problems and needed assistance with toileting hygiene and personal hygiene.
A resident with severe cognitive impairment, aphasia, and other diagnoses had a soft touch call light repeatedly observed draped on the bed rail and out of sight and reach while he was in bed. The care plan included using the bell to call for assistance, and an LPN/TXN stated the device should have been within reach because the resident was physically capable of using it.
A resident’s MAR was left visible on a medication cart computer facing the hall, and two residents were observed walking by with the screen in view. An LPN stated she did not apply the privacy screen when she left the cart to go into a resident’s room, and the DON and ADON confirmed the MAR should not have been left exposed.
Failure to provide ordered pudding with meals. A resident with dementia, severe cognitive impairment, abnormal weight loss, and mild protein calorie malnutrition had a physician order for a mechanical soft diet with pudding at all meals, but an observed breakfast tray did not include pudding. The ADON and Dietary Manager both confirmed the resident should have received pudding and did not.
Failure to maintain grooming, oral hygiene, and clean linen: A resident with severe cognitive impairment and dependent ADL needs was observed unshaven with cracked lips, dry skin, and no oral care provided despite a care plan for daily oral hygiene and weekly shaving. Another resident with severe memory problems and dependent toileting hygiene was observed lying on a soiled bedspread with a dirty adult brief, and a CNA confirmed the linen and brief should have been changed.
Failure to Administer Ordered PRN Nausea Medication: A resident with intact cognition and orders for PRN ondansetron for nausea and vomiting reported ongoing N/V/D and said she asked for medication but did not receive it. The MAR showed only one dose was given, progress notes did not document nursing assessment or treatment of the symptoms, and staff interviews indicated an LPN did not administer the medication despite it being available on the med cart.
Failure to turn two dependent residents with pressure ulcers every 2 hours. Two residents with significant cognitive impairment and existing pressure ulcers were repeatedly observed lying on the same side over several hours, and a CNA confirmed they had not been turned as scheduled. One resident had pressure ulcers to the hip and sacral area, and the other had a heel and midfoot ulcer with diagnoses including PVD and malnutrition.
Failure to Obtain Ordered Medication: A resident with DM2, paranoid schizophrenia, and HTN had an order for Farxiga 10 mg daily, but the medication was not obtained from the pharmacy. An LPN administered the resident’s other meds, used Farxiga from a discharged resident, and did not notify the DON or ADON that the ordered medication had not been received.
An LPN left a bottle of Aspirin 81 mg and a bottle of Geri-Kot 8.6 mg unattended on top of a medication cart on Hall B while two residents walked by. The LPN later confirmed she should have placed the meds in the locked cart, and the DON and ADON confirmed the OTC meds were not supposed to be left unattended.
Dietary support functions were performed by untrained housekeeping and floor staff who assisted in the kitchen during staffing shortages. These staff were shown how to operate the dishwashing machine but were not trained to verify water temperature or chemical levels for proper sanitation. They reported that dishes remained partially wet after the rinse cycle and that the dietician instructed them to use dry towels to finish drying plates and cups before storing them, contrary to facility policy requiring air drying to avoid re-contamination. This practice had the potential to affect all residents receiving meals from the kitchen.
The facility did not maintain sufficient dietary staffing, resulting in frequent morning shifts with only one dietary worker responsible for preparing multiple regular, chopped, and pureed meals for residents. Dietary staff reported routinely working short and relying on staff from other departments to assist with dishwashing, even though these helpers were not trained in kitchen procedures and were only shown basic dishwashing tasks. The Dietary Manager and DON were aware that single-staff coverage occurred and that untrained non-dietary personnel were being used to support kitchen operations.
Surveyors found that kitchen staff did not follow facility policies for sanitary food service and equipment storage. A dusty fan was positioned close to a food prep table and was blowing directly onto desserts while they were being portioned. Ice scoops were kept in an uncovered bucket on a prep table shelf and were used to fill residents’ cups with ice before being returned to the uncovered container, despite policy requiring scoops to be stored to prevent contamination. Residents’ cups were stored upright and uncovered instead of inverted or covered as required. Infection control staff later confirmed that the fan should not have been directed at food and that ice scoops and cups should have been properly covered or inverted, while the dietary manager reported she was unaware of these storage requirements.
The facility failed to oversee and manage kitchen sanitation and monitoring practices, resulting in dusty equipment operating near exposed food, improperly stored cups and ice scoops, and water accumulation under the ice machine. Required logs for food line temperatures, refrigerator temperatures, coffee/hot beverage temperatures, QAC testing of the 3-compartment sink, and daily kitchen cleaning were incomplete or missing for multiple days. A cook reported a nonfunctioning soap dispenser for months, lack of sanitizer test strips, and absence of proper temperature-recording forms, leading staff to document on napkins. The contracted RD conducted only brief twice-monthly walkthroughs and was unaware of these issues, the dietary manager had no formal orientation and did not know required checks and equipment were not functioning or that supplies and forms were lacking, and the administrator was also unaware of the kitchen problems or equipment failures.
The facility failed to maintain safe and properly functioning kitchen equipment when staff did not report or monitor a longstanding leak under an ice machine and a broken soap dispenser at a three-compartment sink. Surveyors observed a large puddle of water beneath the ice machine, which the dietary manager and maintenance staff were unaware of, while a cook later reported the leak had been present for months but had not been reported. Surveyors also observed a cook manually adding pot and pan dish soap to the sink because the automatic dispenser had been broken for months, and the cook did not know the correct amount of soap to use, a problem the dietary manager also did not know about.
The facility failed to assess two residents for entrapment risks and did not obtain informed consent before using side rails. One resident, with a history of Hemiplegia and Bipolar Disorder, experienced entrapment resulting in a skin tear. Another resident with Vascular Dementia had side rails used without assessment or consent. The facility's policy requiring risk assessment and consent was not followed, leading to potential safety risks.
A resident with severe cognitive impairment was found with a serious leg injury of unknown origin, confirmed by X-ray as fractures. The facility's policy requires immediate reporting of such incidents to the state survey agency, but the Administrator failed to do so despite being informed by the DON. The oversight was acknowledged during interviews.
A facility failed to include the use of side rails in a resident's care plan, despite policy requirements. The resident, with conditions such as hemiplegia and bipolar disorder, had side rails in use without documentation in their Plan of Care. Observations and staff interviews confirmed the oversight.
A facility failed to maintain accurate medical records for a resident with chronic pain syndrome. The EMAR lacked documentation of Tylenol administration, despite the LPN's progress notes indicating the resident was in pain and assessed. The DON confirmed the documentation should have been completed.
A resident with specific dietary needs did not receive proper pleasure feedings due to inadequate training of CNAs. The resident's care plan required specific feeding techniques, including small bites, chin tucking, and remaining elevated post-meal. However, a CNA failed to follow these guidelines, and the DON did not ensure other staff were trained when the designated Restorative CNA was unavailable.
A resident was found with medication at their bedside without an order for self-administration or an assessment by the interdisciplinary team. The facility's policy requires such an assessment to ensure safety, but it was not conducted. Staff interviews confirmed the medication should not have been left with the resident, indicating a lapse in following the facility's procedures.
A facility failed to honor a resident's right to refuse care, specifically a bed bath, despite the resident's moderate cognitive impairment and multiple health conditions. The resident expressed a desire to refuse or delay the bath on days she did not feel well, but the CNA insisted on daily baths for all residents, disregarding the resident's choice and self-determination.
A resident's medical records were exposed when a medication cart was left unattended and unlocked outside the dining room area, allowing personal information to be visible to others. The facility's policy requires the use of a privacy screen when the computer is out of view, but an LPN confirmed she did not activate it, resulting in a breach of confidentiality.
A resident's care plan was not updated to reflect her wish to transfer to another facility, despite multiple requests and grievances. The resident's electronic health record and MDS assessment indicated a goal to remain in the facility, which was not revised by the interdisciplinary team. Interviews confirmed awareness of the resident's transfer request, but the care plan remained unchanged.
The facility failed to ensure medication carts were locked when unattended. Observations revealed that two medication carts were left unlocked and unattended in different areas of the facility. Staff confirmed that the carts should have been secured according to facility policy.
A resident with chronic health conditions and moderate cognitive impairment was unable to use the emergency call light in the bathroom due to a malfunction. The resident had to use a cellphone to contact a representative for help. The issue was confirmed by the surveyor, Administrator, and Maintenance Supervisor, but the DON was not informed, preventing interim accommodations.
A facility failed to notify a resident's physician when the resident's smoking privileges were revoked and nicotine mints were administered without a physician's order. The resident, who had intact cognition and was dependent on staff for care, was found to have nicotine mints in his room, provided by his grandmother. Interviews with staff revealed that the physician was not informed of these changes, leading to a deficiency in the resident's care plan.
A facility admitted a resident with a qualifying mental disorder without completing the required preadmission screening by the State Office of Behavioral Health. The resident's level 1 PASRR screening failed to include their diagnosis of Major Depressive Disorder, and no level 2 PASRR was completed. The Social Services Director confirmed the oversight during an interview.
The facility failed to develop comprehensive person-centered care plans within 7 days of completing the required MDS assessments for five residents with various diagnoses, as confirmed by the MDS Coordinator due to time constraints.
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. One resident's oxygen tubing and humidifier were found on the floor, while another's nebulizer and oxygen equipment were left open to air and not labeled. Staff confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled.
The facility failed to ensure proper medication storage and administration, including leaving medication at a resident's bedside, unattended medications on a cart, a controlled medication taped back into a blister pack, and improper storage of medications with food items in a refrigerator.
A resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These conditions were confirmed by the Housekeeping/Maintenance Supervisor as unacceptable.
The facility failed to develop comprehensive care plans for two residents, one with Alzheimer's disease who was improperly positioned in an oversized wheelchair, and another with Parkinson's Disease who was not care planned for limited range of motion. Staff confirmed the lack of appropriate documentation and care planning for both residents.
A resident with Alzheimer's Disease and high risk for pressure ulcers had a stage 3 pressure ulcer identified, but the facility failed to assess and document the ulcer until three days later. Interviews with staff confirmed the delay in assessment and treatment.
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident with severe cognitive impairment. The resident was observed without a chair alarm, despite the care plan indicating its use. The resident had a history of falls, including incidents where the bed alarm was malfunctioning or not in place, leading to injuries. Interviews with staff confirmed these findings.
The facility failed to ensure proper medication management for two residents. One resident did not receive their prescribed Plavix due to a failure in the re-ordering process, while another resident's Percocet count did not match the reconciliation sheet, and the medication was not signed as given.
The facility failed to maintain an effective infection control program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. Two LPNs were observed not following hand hygiene protocols, which was confirmed during interviews. This practice had the potential to affect the 70 residents in the facility.
The facility failed to post the most recent survey results in a place accessible to residents, family members, and legal representatives. The binder near the main entrance only contained older survey results, and the Administrator confirmed the absence of the latest complaint survey results.
Infection Surveillance and PPE Use Failures
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program by not using a surveillance system that included pathogen data to identify possible communicable diseases or infections before they spread. The facility policy for surveillance required the infection preventionist to conduct ongoing surveillance for healthcare-associated and other significant infections and to summarize monthly data by site and by pathogen. However, review of the Infection Surveillance Information Forms for February, March, and April 2026 showed that not all pathogens from culture results were recorded for infection surveillance, and the corresponding monthly infection control maps did not include specific pathogens. The infection control nurse and the DON confirmed that the specific pathogens from lab results were not recorded and tracked on the monthly maps as required by the facility's protocol. The facility also failed to ensure staff used PPE according to accepted standards of practice during high-contact care for two residents on enhanced barrier precautions. Resident #27 had diagnoses including metabolic encephalopathy, gastrostomy, and Kennedy ulcers to the right hip and sacrum, and had an order for enhanced barrier precautions during high-contact activities every shift. Resident #54 had diagnoses including peripheral vascular disease, atherosclerosis of the arteries of the left leg with ulceration, and a Stage IV pressure ulcer, and also had an order for enhanced barrier precautions during high-contact activities every shift. Staff were observed changing Resident #27's adult brief and changing Resident #54's soiled linen and adult brief without wearing gowns. One CNA stated she was not aware the residents were on enhanced barrier precautions, and the infection control nurse confirmed gowns and gloves should have been worn during those care activities.
Food Preparation and Milk Safety Deficiency
Penalty
Summary
The facility failed to ensure food was prepared according to recipe and that potentially hazardous food was served in a safe manner. On 06/08/2026, a cook prepared mashed potatoes without using the facility recipe. The recipe for Mashed Potatoes DHY/Gravy called for potato granules, water, and soft margarine bulk, with instructions to prepare the potatoes according to package directions and omit salt. Instead, the cook poured an undetermined amount of water, potato flakes, milk, and salt into a container, mixed them with a whisk, and then added an undetermined amount of granulated onion powder to give the potatoes more flavor. The dietary manager confirmed the kitchen should have used the recipe, and the cook acknowledged she did not use it. The facility also served spoiled milk to residents. Resident #38 had an unfinished glass of milk on the breakfast tray, stated it tasted sour, and a smell test confirmed the milk smelled spoiled. Resident #58, who had a BIMS score of 15 and was cognitively intact, stated his breakfast milk tasted spoiled and he could not finish it. The next day, he was observed with a carton of milk that had an expiration date of 06/10/2026 but had a sour odor. A CNA and the dietary manager both smelled the milk and confirmed it did not smell fresh, and the dietary manager discarded it and replaced it with milk from a gallon. The administrator was later informed that Resident #58 had been served milk that smelled spoiled with breakfast.
Kitchen sanitation, labeling, and spoiled milk served
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional food service standards when kitchen entry controls, date labeling, and milk handling were not followed. On 06/08/2026, two maintenance personnel were observed in the kitchen without hair protection, including one with a beard who also did not have beard protection, despite the facility policy requiring hair nets or other approved coverings for anyone entering the dietary department and beard restraints for staff with facial hair. The dietary manager later confirmed that any staff entering the kitchen should wear hair and/or beard protection. The facility also failed to label refrigerated food properly. During an observation of the walk-in cooler, a plastic bag containing unwrapped slices of cheese was found on a shelf without an open date. The dietary manager stated that the bag should not have been placed in the cooler without an open date. The facility policy required all refrigerated, ready-to-eat foods that are prepared, opened, or portioned to be labeled immediately upon opening with the food name, date prepared or opened, and expiration or discard date. Residents also reported receiving spoiled milk on breakfast trays, and surveyors confirmed milk that smelled and tasted spoiled. Two residents stated they received spoiled milk, one in a carton and one in a glass. The dietary manager poured several glasses of milk from a gallon that had an open date of 06/06/2026 and use-by date of 06/10/2026, but stated she had not used that gallon for the glasses she prepared and had discarded the gallon she did use. Surveyors tasted and smelled the gallon in the cooler and found it spoiled, and the dietary manager confirmed the odor. Another cook used a carton of milk with a 06/10/2026 use-by date to make mashed potatoes, and surveyors, the cook, and another staff member all confirmed that milk had a sour odor and was spoiled. Despite these findings, the administrator stated the staff had done nothing wrong because the milk had not reached the expiration date and planned to continue serving the remaining milk. The next morning, a resident again reported receiving spoiled milk, and the dietary manager confirmed the carton smelled sour.
Failure to Maintain Privacy During Peri-Care
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring privacy during perineal care for two residents. Resident #27 had a quarterly MDS dated 04/16/2026 showing a BIMS score of 00, indicating severe cognitive impairment, and was dependent on staff for personal hygiene. Resident #54 had an MDS showing a BIMS score of 09, indicating severe problems with thinking or memory, and was dependent for toileting hygiene and needed partial/moderate assistance with personal hygiene. During an observation on 06/08/2026 at 2:24 p.m., S6CNA and S7CNA were observed providing peri-care to Resident #54, who was the roommate of Resident #27, while changing soiled linen and an adult brief. The room door was not closed, the privacy curtain between the beds was not pulled, and the window blind remained up, leaving Resident #27's genitalia exposed. Later that same day at 2:50 p.m., S6CNA and S7CNA were observed providing peri-care to Resident #27 while the room door was left open, the privacy curtain was not used, and the window blinds remained up, leaving Resident #54's genitalia exposed. At 3:00 p.m., S7CNA confirmed that the privacy curtain, blinds, and door should have been closed before providing peri-care.
Call Light Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure a soft touch call light device was within reach for Resident #27, who was admitted with diagnoses including metabolic encephalopathy, aphasia, paranoid schizophrenia, and dysphagia. His MDS quarterly assessment dated 04/16/2026 showed a BIMS score of 00, indicating severe cognitive impairment, and his care plan dated 02/17/2026 identified an ADL self-care performance deficit with an intervention to encourage him to use the bell to call for assistance. During multiple observations on 06/08/2026, 06/09/2026, and 06/10/2026, the resident was found lying in bed with the soft touch call bell draped on the bed rails or outside of his sight and reach. An interview with S8IC/TXN confirmed the call bell should have been within the resident's reach and stated the resident was physically capable of using it.
Resident MAR Left Visible on Medication Cart Computer
Penalty
Summary
The facility failed to keep a resident’s medical records confidential when Resident #44’s MAR was left visible on a computer screen mounted on a medication cart in Hall B. On 06/09/2026 at 8:38 a.m., the MAR was observed facing the hall with the resident’s prescribed medication information displayed, and two residents were seen walking by the cart with the screen in view. S10LPN stated that she did not apply the computer privacy screen when she left to go into a resident’s room and acknowledged that she should have. On 06/10/2026 at 2:45 p.m., S1DON and S2ADON confirmed that S10LPN should not have left Resident #44’s MAR information on the computer without applying the privacy screen.
Failure to Provide Ordered Pudding With Meals
Penalty
Summary
The facility failed to follow Resident #4’s physician order for pudding with all meals. Resident #4 was admitted on 01/02/2025 with diagnoses including dementia with other behavioral disturbance, abnormal weight loss, and mild protein calorie malnutrition, and an MDS dated [DATE] showed a BIMS score of 00, indicating severe cognitive impairment. Physician orders dated 06/09/2026 specified a regular mechanical soft diet with pudding with all meals. During observation on 06/10/2026 at 8:57 a.m., the resident’s breakfast tray contained grits, sausage, eggs, milk, orange juice, and water, but no pudding. During interviews, the ADON confirmed the resident was supposed to have pudding on the breakfast tray and did not receive it, and the Dietary Manager stated she was aware the resident’s diet had changed to include pudding with all meal trays and confirmed the resident did not receive pudding that morning.
Failure to Maintain Grooming, Oral Hygiene, and Clean Linen
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain grooming and oral hygiene. Resident #27, who was admitted with diagnoses including metabolic encephalopathy, aphasia, a pressure ulcer to the right hip and sacrum, type 2 diabetes mellitus, and dysphagia, had a care plan that included daily oral care and physician orders for Aquaphor to the bilateral upper and lower extremities for dryness. The resident’s MDS indicated severely impaired cognitive skills, dependent oral care, and personal hygiene needs. During observations, the resident was found unshaven with a dry face, cracked lips, and a moderate amount of dry skin on the lips and face. A CNA stated she was responsible for the resident’s care but had not provided oral hygiene or grooming that day, and the DON confirmed the resident should have been monitored and shaved at least weekly. The facility also failed to ensure that Resident #54’s brief and linen were clean. This resident was admitted with diagnoses including atherosclerosis of the arteries of the left leg with ulceration of the heel and midfoot, peripheral vascular disease, and protein-calorie malnutrition. The admission MDS showed a BIMS score of 09, indicating severe problems with thinking or memory, with partial/moderate assistance needed for personal hygiene and dependent assistance for toileting hygiene. During observation, the resident was lying on a bedspread being used as an incontinence pad, and the bedspread had a moderate amount of dry, dark substance. The adult brief had a light brown substance on the outside, and a later observation showed the same soiled bedspread and brief. A CNA confirmed the brown substance on the brief and the dry dark substance on the bedspread and stated she should have changed the soiled linen and brief.
Failure to Administer Ordered PRN Nausea Medication
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with physician orders and professional standards of practice when the resident complained of nausea and vomiting. The resident was admitted with diagnoses including bilateral primary osteoarthritis of the knee, anxiety disorder, pain unspecified, drug induced constipation, and major depressive disorder, and had intact cognition on the quarterly MDS. The physician had ordered Ondansetron HCL 8 mg orally every 6 hours as needed for nausea and vomiting, but the June 2026 MAR showed the medication was administered only once on 06/02/2026, with no additional doses given despite the resident reporting ongoing nausea and vomiting. On 06/08/2026, the resident stated she had experienced diarrhea, nausea, and vomiting since the prior day and reported that she had asked the day shift nurse for nausea medication but was told the facility was out of it. The resident said she still had not received the medication and had vomited the previous afternoon. The progress notes contained no entry showing the nausea was identified and treated by a nurse. Staff interviews showed the CNA reported the resident was sick and had vomited and had diarrhea, and the LPN stated she checked the cart, did not find Zofran there, was told pharmacy did not pass on the weekend, did not call the DON, and left work without giving the resident nausea medication. Later review showed a full blister pack of Ondansetron was on the medication cart, and the DON stated the medication was available for administration.
Failure to Turn Two Dependent Residents With Pressure Ulcers Every Two Hours
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when two dependent residents with pressure ulcers were not turned every two hours. Resident #27 was admitted with diagnoses including metabolic encephalopathy, skin and subcutaneous tissue disorders, type 2 diabetes mellitus, peripheral vascular disease, and pressure ulcers to the right hip and sacral area. His care plan included assistance with bed mobility and repositioning, and his MDS quarterly assessment showed a BIMS score of 00, indicating severe cognitive impairment. During repeated observations on 06/08/2026, he was seen lying on his left side at 9:30 a.m., 11:53 a.m., 1:10 p.m., and 2:00 p.m., and at 2:20 p.m. the CNA confirmed he was supposed to be turned every two hours and had not been turned in two hours. Resident #54 was admitted with diagnoses including atherosclerosis of the arteries of the left leg with ulceration of the heel and midfoot, peripheral vascular disease, and protein-calorie malnutrition. His care plan stated he needed reminding and assistance to reposition at least every two hours, and his admission MDS showed a BIMS score of 09, indicating severe problems with thinking or memory. On 06/08/2026, he was observed lying on his right side at 9:30 a.m., 11:53 a.m., 1:10 p.m., and 2:00 p.m., and at 2:20 p.m. the CNA confirmed he was supposed to be turned every two hours and had not been turned in two hours. On 06/10/2026, the Infection Control/Treatment Nurse and CNA confirmed both residents were supposed to be turned every two hours.
Failure to Obtain Ordered Medication
Penalty
Summary
The facility failed to obtain an ordered medication from the pharmacy for one resident who was admitted with diagnoses including type 2 diabetes mellitus without complications, paranoid schizophrenia, and essential hypertension. The resident had a physician order dated 06/01/2026 for Farxiga 10 mg by mouth daily for diabetes, but during morning medication administration on 06/09/2026, the LPN administered the resident’s other medications and did not give Farxiga because it had not been received from the pharmacy. The LPN stated the Farxiga had been ordered on 06/01/2026 but had still not arrived, and she reported that she had been using Farxiga from another resident who had been discharged, with the last tablet used on 06/08/2026. The MAR showed Farxiga was administered from 06/02/2026 through 06/08/2026. During follow-up, the LPN stated she later called the pharmacy and was told the order had not been received, and the ADON stated the order had been faxed but the LPN did not report the missing medication or the use of another resident’s medication.
OTC Medications Left Unattended on Medication Cart
Penalty
Summary
The facility failed to appropriately store OTC medications in a locked medication cart. On 06/08/2026 at 9:33 a.m., surveyors observed an unattended medication cart on Hall B with a bottle of Aspirin 81 mg and a bottle of Geri-Kot 8.6 mg left on top of the cart. Two residents walked by the parked cart while the medications were unattended. After 5 minutes, S10 LPN returned to the cart and confirmed that she had left the medications on top of the cart and stated that she should have placed the medications in the locked cart. The facility policy titled Medication Labeling and Storage stated that all medications and biologicals are stored in locked compartments, and S1 DON and S2 ADON confirmed that the nurse was not supposed to have left the medications on the cart unattended and that the OTC medications should have been placed in the locked cart.
Untrained Support Staff Improperly Operating Dishwasher and Drying Dishes
Penalty
Summary
The facility failed to ensure that dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service, specifically related to dishwashing and sanitization. The facility’s cleaning policy stated that once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry and that the use of towels may re-contaminate sanitized surfaces. The head of housekeeping services reported that, due to kitchen staffing shortages beginning in early 2026, housekeeping and floor staff were used to assist in the kitchen on their days off, including washing dishes. She acknowledged that she had not trained these staff members on the proper procedure for washing dishes. The cook confirmed that staff from other departments had been helping in the kitchen when they were short staffed and verified that towels should not be used to finish drying dishes after the dishwasher cycle, although dishes also should not be put away while still wet. Housekeeping and floor staff who assisted with dishwashing confirmed they had been instructed by the dietician on how to operate the dishwashing machine and how to load and unload racks, but they were not trained on checking water temperature or verifying chemical levels for proper sanitation. These staff members reported that after the rinse cycle, dishes remained partially wet and that the dietician had instructed them to use a dry towel to completely dry plates and cups before placing them in cabinets. One staff member stated he had been told about temperature and chemicals but assumed someone else checked them and did not perform these checks himself. The dietician confirmed that he had instructed these staff members on using the dishwashing machine and acknowledged that he should not have told them to use a dry towel to complete drying the dishes. This deficient practice had the potential to affect any of the 74 residents who received meals from the facility’s kitchen.
Insufficient Dietary Staffing and Use of Untrained Support Personnel
Penalty
Summary
The facility failed to ensure sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service for 74 residents receiving meals from the kitchen. Review of the dietary schedule for a two-week period showed multiple days when only one staff member was scheduled for the morning shift. During an observation of the kitchen, two dietary staff were present, and one staff member reported that on many days they had to work short and that staff from other departments were brought in to help. She confirmed that these non-dietary staff were not trained on kitchen procedures and were only shown how to wash dishes. On another morning observation, only one dietary staff member was present in the kitchen preparing multiple breakfast items, including regular, chopped, and pureed foods, with no other dietary staff scheduled or present. This staff member confirmed she was working alone and that the Dietary Manager was aware in advance that she was the only person scheduled for that shift. She also stated that when she did not have help, the DON would send staff from other departments to assist with dishwashing. Another dietary staff member corroborated that the kitchen was often short staffed and that untrained staff from other departments were used to wash dishes, confirming they had not been trained in kitchen procedures.
Unsanitary Food Prep, Ice Scoop, and Dishware Storage Practices in Kitchen
Penalty
Summary
The deficiency involves failure to follow professional standards and facility policies for sanitary food service, ice scoop storage, dishware storage, and equipment monitoring in the kitchen, potentially affecting 74 residents who received food from this area. During a kitchen observation, a black fan with visible dust on the grill and blades was positioned about two feet from a food prep table and was blowing directly toward the area where a staff member was cutting lemon pie and placing slices into individual bowls. Facility policy required food to be protected from contamination, and the Infection Control staff later confirmed the fan should not have been directed toward food preparation and should have been clean and free of visible dust. Further observations showed an uncovered white plastic bucket on a prep/condiment table shelf containing three ice scoops, including a large silver scoop that a staff member used to fill residents’ drinking cups with ice before returning it to the uncovered bucket, contrary to the facility’s ice scoop storage policy requiring scoops to be stored and maintained to prevent contamination. Additional observations revealed residents’ cups stored upright and uncovered on a black shelf, despite the facility’s dishware/utensil storage policy requiring items to be stored inverted or covered. In interviews, the Infection Control staff confirmed that ice is considered a food item and scoops should be covered when not in use, and that cups should be stored inverted. The Dietary Manager stated she was not aware that scoops needed to be covered or bagged and that cups had to be stored inverted or covered, and also confirmed that a fan should not have been used in the kitchen during meal prep.
Failure to Oversee Kitchen Sanitation, Monitoring, and Equipment in Dietary Services
Penalty
Summary
The facility failed to administer and oversee kitchen practices to ensure safe food service for 74 residents who consumed meals prepared there. Policy review showed written procedures for proper ice scoop storage, dishware/utensil storage, and three-compartment sink QAC (quaternary ammonium compound) testing, but surveyors found these were not being followed. During a kitchen tour, a black fan in active use had visible dust on its grill while a cook stood with her back to the fan slicing lemon pie on a prep table and placing slices into bowls for residents. Nearby, clear plastic cups were stored on an open shelf without being inverted or covered, contrary to the facility’s dishware storage policy. Further observations revealed an uncovered white plastic bucket containing three uncovered scoops and a large puddle of water on the floor beneath the ice machine, despite the facility’s policy requiring ice scoops to be stored and maintained to prevent contamination. Review of multiple monitoring logs showed significant gaps and missing documentation. The food line temperature log had entries only for a single date, the daily kitchen cleaning schedule showed only one recent entry for mopping the dish area and coffee station, and the three-compartment sink QAC log had only two entries noting “no strips” with no further documentation. Refrigerator temperature logs stopped at the end of one month, and the coffee/hot beverage temperature log contained numerous days with no recorded temperatures. On observation of three-compartment sink use, a cook was seen squeezing soap directly into the basin because the dispenser had not worked properly for about three months. She reported that there had been no test strips to check sanitizer concentration since a specific date and that staff lacked proper forms to record food line temperatures, resorting to writing temperatures on napkins. In interviews, the contracted RD stated she had little oversight of the dietary manager, made only twice-monthly walkthroughs for cleanliness, and was unaware of the kitchen issues, relying on dietary managers to maintain the kitchen. The dietary manager reported she had not been oriented to the kitchen, was unaware that required temperature and chemical checks were not being done, did not know the three-compartment sink was not functioning properly, and did not know staff lacked test strips and temperature forms. The administrator also stated he was not aware of the various kitchen issues or that some equipment was not working properly and indicated the RD was responsible for ensuring the dietary manager fulfilled her duties.
Failure to Maintain Safe and Properly Functioning Kitchen Equipment
Penalty
Summary
The facility failed to keep essential kitchen equipment in safe working condition by not ensuring timely reporting and monitoring of an ice machine leak and a malfunctioning three-compartment sink soap dispenser. During a kitchen observation, surveyors noted a large puddle of water pooled beneath the ice machine, and the dietary manager stated she was unaware of the leak. The maintenance staff member reported that kitchen staff had not informed him of any leak nor documented it in his maintenance logbook. A cook later stated that the ice machine had been leaking for at least three months but acknowledged she had not reported it to maintenance, assuming the dietary manager would address it. In the same kitchen observation, the three-compartment sink was found to have a non-functioning automatic soap dispenser. A cook was observed manually squeezing pot and pan dish soap into the sink basin and stated the dispenser had been broken for at least three months. When questioned, she admitted she did not know how much soap she was adding. The dietary manager also stated she was not aware that the three-compartment sink was not working properly.
Failure to Assess and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for the risk of entrapment from side rails, and informed consent was not obtained prior to their installation. Resident #2, who had a history of Hemiplegia and Hemiparesis, Bipolar Disorder, and Major Depressive Disorder, was found with his left leg entrapped between the side rail and the mattress, resulting in a skin tear. Despite this incident, there was no evidence of an assessment for the risk of entrapment, nor was there informed consent from the resident or his representative for the use of side rails. Additionally, ongoing monitoring and supervision of the side rails were not conducted. Resident #3, diagnosed with Vascular Dementia and Hemiplegia, was also not assessed for the risk of entrapment before the use of side rails. The resident's care plan included the use of side rails for bed mobility and repositioning, but there was no informed consent obtained from the resident or their responsible party. Observations confirmed that both upper half side rails were in the upward position, yet no assessment or consent documentation was found in the resident's medical record. Interviews with the Director of Nursing confirmed the lack of assessments and informed consents for both residents. The facility's policy on side rails, which requires an assessment of risks and benefits and obtaining consent, was not followed. This oversight led to the continued use of side rails without proper evaluation and documentation, posing a potential risk to the residents' safety.
Failure to Report Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown origin to the state survey agency within the required timeframe. The facility's policy mandates that any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, or within two hours if the incident involves serious bodily injury. However, in this case, the facility did not adhere to this policy. On October 23, 2024, a resident with severe cognitive impairment was found with a swollen and misaligned right lower leg, indicating a serious injury. An X-ray confirmed comminuted displaced fractures of the tibia and fibula. The Director of Nursing (DON) was informed of the injury on the same day and notified the Administrator. Despite this, the Administrator did not report the incident to the state survey agency as required. The failure to report was confirmed during interviews with both the DON and the Administrator. The Administrator acknowledged the oversight and confirmed that the resident was sent to the hospital for treatment of the injury, which was of unknown origin.
Failure to Document Side Rail Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident by not including the use of side rails in the Plan of Care. The facility's policy on physical restraints and side rails, last reviewed in January 2024, mandates that the use of side rails as assistive devices must be addressed in the resident's care plan. However, a review of the resident's medical record revealed that there was no documentation regarding the use of side rails, despite the resident having been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, bipolar disorder, and major depressive disorder. An observation on November 21, 2024, noted that the resident's bed had the left upper side rail in the upward position and the right upper side rail in the downward position, with the bed's right side against the wall. A CNA confirmed that the side rails had been used in this manner since she began working at the facility a month prior. The Director of Nursing also confirmed that the use of side rails was not documented in the resident's Plan of Care, indicating a failure to adhere to the facility's policy and ensure the resident's care plan was comprehensive and person-centered.
Incomplete Documentation in EMAR for Pain Management
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the sampled residents. Specifically, the Electronic Medication Administration Record (EMAR) for a resident was incomplete and inaccurately documented. The resident, who was admitted with diagnoses including Muscle Wasting and Atrophy, Osteoporosis, Osteoarthritis, and Chronic Pain Syndrome, had a physician's order for Tylenol to be administered as needed for pain. On a specific date, a Licensed Practical Nurse (LPN) was notified by a Certified Nursing Assistant (CNA) to assess the resident, who was in pain and unable to move or flex her right foot. Despite the LPN's progress notes indicating that the resident was assessed and in pain, there was no documentation in the EMAR that Tylenol was administered to the resident at that time. During an interview, the Director of Nursing (DON) confirmed that nurses are required to document all administered medications in the EMAR and acknowledged the absence of documentation for the administration of Tylenol, which should have been recorded.
Inadequate Training for Pleasure Feedings
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in administering pleasure feedings to a resident with specific dietary needs. The resident, who had a history of malnutrition, vitamin D deficiency, type 2 diabetes, and chronic kidney disease, required PEG tube feedings along with pleasure feedings. The resident's care plan, as outlined in a Speech Therapy Discharge Summary and Restorative Nursing Program Recommendations, specified that the resident should receive small bites and sips, be cued to tuck their chin and double swallow, and remain in an elevated position for at least thirty minutes after eating. However, during an observation, a CNA provided the resident with puree eggs and honey-thickened liquids through a straw without following these guidelines, failing to cue the resident appropriately and allowing the resident to lower their bed immediately after eating. Interviews revealed that the CNA was not aware of the specific feeding instructions and had not been trained on the resident's pleasure feeding protocol. The Director of Nursing (DON) had received the resident's restorative plan but did not ensure that other staff members were trained to administer the feedings when the designated Restorative CNA was unavailable. The facility's administrator acknowledged that the restorative program was specific and did not consider it feasible to train other CNAs on these tasks. This lack of training and communication led to the deficiency in care for the resident.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The interdisciplinary team did not assess the resident's mental and physical abilities to determine if self-administration was clinically appropriate. The resident, who had a BIMS score indicating intact cognition, was observed with two medicine cups containing a liquid medication at their bedside. The medication was identified as magic mouthwash, which was prescribed for the resident's sore mouth. However, there was no physician's order allowing the resident to self-administer this medication, nor was there an assessment or care plan in place to support self-administration. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the medication should not have been left at the resident's bedside. The LPN denied leaving the medication and was unsure who did, while the Director of Nursing confirmed the absence of an order for self-administration. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, which requires a formal assessment and documented approval by the interdisciplinary team.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not accommodating a resident's choice to refuse care. The resident, who has moderate cognitive impairment and multiple health conditions including COPD, coronary artery disease, and depression, expressed a desire to refuse a bed bath on certain days when she did not feel well. Despite this, the facility's staff, specifically a CNA, did not honor the resident's request to refuse or delay the bath, insisting that all residents receive a daily bath regardless of their wishes. Interviews with the resident revealed that she was not allowed to refuse a bed bath, and her request to have a bath at a later time was not honored. The CNA confirmed that residents who do not go to the whirlpool receive a bed bath daily and did not acknowledge the resident's right to refuse care. The CNA stated that everyone wants to feel clean and did not provide an option for the resident to refuse a bath, even for hospice residents, indicating a lack of support for resident choice and self-determination.
Breach of Resident Confidentiality Due to Unattended Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, as observed during a survey. The incident involved a medication cart, identified as Medication Cart B, which was left unattended and unlocked outside the dining room area. This allowed the personal information of one resident to be visible to visitors and other residents. The facility's policy on the security of medication carts requires that a computer privacy screen be initiated when the computer is out of the nurse's view. However, during an interview, an LPN confirmed that she did not activate the privacy screen before leaving the cart unattended, leading to the breach of confidentiality.
Failure to Update Resident's Care Plan for Transfer Request
Penalty
Summary
The facility failed to ensure that a resident's person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the sampled residents, who had expressed a desire to transfer to another facility. Despite the resident's grievance and multiple requests for transfer, the care plan continued to reflect the resident's goal to remain in the facility. The resident's electronic health record indicated that she was admitted with diagnoses including urinary tract infection, chronic kidney disease, schizophrenia, and bipolar disorder. Her 5-day Minimum Data Set (MDS) assessment also noted her goal to stay in the facility, which was not updated to reflect her current wishes. Interviews with the Social Service Director and the MDS coordinator revealed that the resident had repeatedly requested a transfer, and efforts were made to facilitate this, including communication with other facilities. However, these requests were denied, and the care plan was not updated to reflect the resident's current goal of transferring. The MDS coordinator acknowledged awareness of the resident's wish to transfer and confirmed that the care plan should have been revised to reflect this change.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. On Hall A, Medication Cart A was found unlocked and unattended while an LPN was engaged in a personal phone call at the nurse's station. The LPN confirmed that the cart should have been locked before leaving it unattended. Similarly, on Hall B, Medication Cart B was observed unlocked and unattended near the nurse's station, with a visitor present in the hallway. The Assistant Director of Nursing confirmed that the cart should have been secured. Further observations revealed that Medication Cart B was again found unlocked and unattended outside the dining room area. An LPN confirmed that the cart should have been locked before leaving it unattended. These observations indicate a failure to adhere to the facility's policy requiring medication carts to be locked when not in use, posing a potential risk to the security of medications.
Non-Functional Call System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that the resident call system was functioning properly for one of the sampled residents. The deficiency was identified when a resident, who had been admitted with multiple chronic conditions including Chronic Systolic Heart Failure and Type 2 Diabetes Mellitus, attempted to use the emergency call light in the bathroom but found it non-functional. The resident, whose cognitive status was moderately impaired, had an accident and was unable to summon help using the call light. Instead, he had to call his representative via cellphone, who then contacted the facility to get assistance for him. Upon investigation, the surveyor confirmed that the call light in the resident's bathroom did not work, as it failed to activate the indicator outside the room or alert the front desk. The facility's Administrator and Maintenance Supervisor both verified the malfunction during their checks. The Director of Nursing was not informed about the issue, which prevented any interim measures from being implemented to accommodate the resident's needs until the call light was repaired.
Failure to Notify Physician of Changes in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a resident's physician was consulted when there was a change in the plan of care. Specifically, the facility did not notify the physician when a resident's smoking privileges were revoked due to noncompliance with facility smoking policies. Additionally, the staff administered nicotine mints to the resident without a physician's order. This oversight was discovered during a review of the resident's care plan and electronic medical records, which showed no documentation of physician notification regarding these changes. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, Administrator, and Assistant Director of Nursing, revealed that the resident's physician was not informed of the changes in the resident's care plan. The Social Service Director noted that the resident's grandmother had purchased nicotine mints for the resident, which were being given to him by the CNAs. The Nurse Practitioner confirmed that she was not aware of the resident's loss of smoking privileges or the need for an order for nicotine mints. The Administrator and Assistant Director of Nursing acknowledged that they had not followed up with the physician regarding these changes, leading to the deficiency.
Failure to Complete PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a qualifying mental disorder was not admitted before a preadmission screening by the State Office of Behavioral Health (OBH) was completed. The resident, who was admitted with diagnoses including Anxiety Disorder, Unspecified Mood Disorder, and Major Depressive Disorder, had a level 1 PASRR screening dated 08/17/2023. However, the screening incorrectly indicated no suspected or diagnosed mental illness, and there was no level 2 PASRR completed. During an interview, the Social Services Director confirmed that the resident was admitted with a diagnosis of Major Depressive Disorder from another facility and acknowledged that this diagnosis should have been included in the level 1 screening.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS for five residents. The residents involved had various diagnoses, including Hepatitis A, Type 2 Diabetes Mellitus, Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Heart Failure, Schizoaffective Disorder, Acute Kidney Failure, Anxiety Disorder, Depression, Chronic Pain Syndrome, Hypertension, Spinal Stenosis, Tachycardia, Dementia, and Congestive Heart Failure. Despite the completion of their Annual MDS assessments, their Electronic Health Records (EHR) did not contain the required comprehensive care plans. An interview with the Minimum Data Set Coordinator (MDSC) revealed that the comprehensive care plans for these residents were not developed due to time constraints and being months behind schedule. The MDSC confirmed the deficiency, acknowledging that the care plans were supposed to be completed but were not. This lapse affected the quality of care planning for the residents involved.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. For Resident #9, who has severe cognitive impairment and a history of acute and chronic respiratory failure, the oxygen tubing and humidifier were found on the floor, open to air, and not labeled. This was confirmed by an LPN who acknowledged that the equipment should have been stored in a bag and labeled with the date. The resident's care plan indicated a need for oxygen therapy as needed, but the facility did not adhere to its own policy or state and federal guidelines for equipment storage and labeling. Similarly, Resident #16, who has moderate cognitive impairment and chronic obstructive pulmonary disease, had a nebulizer with mouthpiece and tubing stored on the dresser, open to air, and without a date. The resident's oxygen tubing and humidifier were also in use but not labeled. A CNA confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled. The Assistant Director of Nursing and Infection Preventionist also confirmed that the facility's procedures were not followed in both cases, leading to the deficiencies observed by the surveyors.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflected current standards of practice. Specifically, medication was left at a resident's bedside without proper authorization or assessment for self-administration. Additionally, medications were left unattended on top of a medication cart, and a controlled medication was found taped back into a blister pack. Furthermore, medications were stored together with food items in a refrigerator, and some medications were not labeled with the resident's name. Resident #31 had Flonase allergy spray left on her bedside table without documented evidence of a request or assessment for self-administration. An LPN confirmed the medication should have been securely stored. Another LPN left multiple medications unattended on top of a medication cart while retrieving a narcotics binder. A random narcotic check revealed a Percocet tablet taped back into a punctured blister pack. Additionally, a tour of a resident's supplement refrigerator found medications stored with food items, and some medications were not labeled with the resident's name.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with Acute Embolism and Thrombosis of Unspecified Deep Veins of the Left Lower Extremity and Moderate Protein Calorie Malnutrition. On two separate observations, the resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These findings were confirmed by the Housekeeping/Maintenance Supervisor, who acknowledged that the conditions were unacceptable.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive plan of care for two residents, leading to deficiencies in addressing their specific needs. Resident #13, diagnosed with Alzheimer's disease, was observed multiple times slouched in an oversized high back wheelchair, which was not appropriate for her size. Despite the family's insistence on using this wheelchair, the care plan did not document this insistence or address the issue. Interviews with staff, including the Director of Nursing and the Minimum Data Set Coordinator, confirmed the lack of documentation and appropriate care planning for the resident's positioning needs. Resident #17, diagnosed with Parkinson's Disease, Muscle Weakness, Repeated Falls, and Contracture of the Right Hand, was not care planned for her limited range of motion. Observations revealed that the resident's right hand was clenched in a fist without a hand roll, and she was unable to open her hand fully. Interviews with staff confirmed that the resident did not have a hand roll and that her limited range of motion was not addressed in her care plan, despite the problem existing at the time the comprehensive care plan was completed.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing. Resident #13, who was diagnosed with Alzheimer's Disease and assessed as high risk for pressure ulcer development, had a pressure ulcer identified on 01/22/2024. However, there was no evidence that an assessment of the pressure ulcer was done on the same day. The first documented assessment of the pressure ulcer was on 01/25/2024, three days after it was initially identified, and it was noted as a stage 3 pressure ulcer with specific measurements and characteristics. Interviews with the Assistant Director of Nursing Infection Preventionist (S3ADONIP) and the Director of Nursing (S2DON) confirmed the lack of timely assessment. S3ADONIP acknowledged identifying the pressure ulcer on 01/22/2024 but could not provide evidence of an assessment on that date. S2DON also confirmed that an assessment should have been done immediately when the pressure ulcer was identified, rather than three days later. This delay in assessment and treatment constitutes a failure to provide necessary care for the resident's pressure ulcer.
Failure to Ensure Adequate Supervision and Assistance to Prevent Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident diagnosed with unspecified dementia with other behavioral disturbances. The resident, who had a severely impaired cognition with a BIMS score of 3, was observed without a chair alarm attached to their wheelchair, despite the care plan indicating the use of bed and chair alarms as fall prevention measures. Interviews with CNAs confirmed the absence of the chair alarm during the observation. Additionally, the resident had a history of falls, including incidents where the bed alarm was either malfunctioning or not in place, leading to injuries such as a skin tear on the right forearm. The resident's electronic clinical record and progress notes revealed multiple falls, including one where the bed alarm was found to be malfunctioning and another where there was no documentation of the bed alarm being in place. Interviews with the Director of Nursing and the Assistant Director of Nursing Infection Preventionist confirmed these findings. The facility's failure to ensure the proper functioning and use of bed and chair alarms contributed to the resident's falls and subsequent injuries.
Failure to Ensure Proper Medication Management
Penalty
Summary
The facility failed to ensure that medications and pharmaceutical services were provided to meet the needs of two residents. For Resident #25, the facility did not re-order and administer Plavix, a blood thinner, as required. The resident's clinical record showed an order for Plavix 75 mg to be taken every other day. On two separate occasions, it was observed that the medication was not available in the medication cart, and the nurse had to call the pharmacy to order it. The Director of Nursing and Assistant Director of Nursing confirmed that the procedure for re-ordering medications was not followed, as they were not notified about the missing medication. For Resident #31, the facility failed to maintain a system to account for the usage and reconciliation of controlled medications. During a random narcotic check, it was found that the number of Percocet pills in the blister pack did not match the count on the narcotic reconciliation sheet. Additionally, the medication was not signed as given on the electronic medication administration record. Both the LPN and RN confirmed the discrepancy and acknowledged that the medication should have been reconciled and signed off at the time it was administered.
Failure to Perform Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. On 04/02/2024, an LPN was observed drawing up insulin, administering it to a resident, and then removing her gloves without performing hand hygiene. She then proceeded to pour medications without sanitizing her hands. During an interview, the LPN confirmed that she did not perform hand hygiene and acknowledged that she should have done so after contact with the resident and removing her gloves. Another LPN was observed on the same day preparing medications without performing hand hygiene after handling a Hoyer lift. She confirmed during an interview that she did not perform hand hygiene before starting to prepare medications and acknowledged that she should have. The Assistant Director of Nursing, who is also the Infection Preventionist, stated that hand hygiene should be performed before and after patient contact and before donning and after removing gloves. This deficient practice had the potential to affect the 70 residents residing in the facility.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to ensure the most recent survey results were posted in a place readily accessible to residents, family members, and legal representatives. During an observation on 04/02/2024, it was noted that the survey results from a complaint survey conducted on 04/11/2023 were not included in the binder labeled LDH DHH Licensing survey, which was located near the facility's main entrance. The binder only contained results from annual surveys conducted on 03/22/2023 and 02/23/2022. The Administrator confirmed the absence of the most recent survey results in the designated area for public review.
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Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near New Iberia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Iberia Manor South | 1 mi | ★★★★★ | 1 | 0 |
| New Iberia Manor North | 3.7 mi | ★★★★★ | 8 | 0 |
| Belle Teche Nursing & Rehab Center | 3.9 mi | ★★★★★ | 11 | 0 |
| Maison Teche Nursing Center | 4.8 mi | ★★★★★ | 9 | 0 |
| Landmark Of Acadiana | 10 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.