Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harvest Manor Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A dietary staff member was observed plating breakfast on the serving line with a mustache and beard and no facial hair restraint. An S3DM noted the issue during the meal service, and an ADM later stated that dietary staff with facial hair should wear a facial hair restraint while preparing and serving food.
Pest Control Failure in Kitchen: The facility failed to maintain an effective pest control program after roaches were documented in the kitchen and later observed repeatedly coming from a hole near the steam table during lunch service. Multiple roaches crawled onto the steam table and toward uncovered food, staff confirmed the bugs were roaches, and a pest control representative reported a roach infestation behind the steam table in the same area previously identified.
Resident council meetings were held in the cafe, which was not private and had openings to the main hallways, while a staff member also entered the area during the meeting. Residents reported ongoing concerns that the council did not have a private space large enough for everyone who wanted to attend, and an attempted meeting in the conference room could not accommodate all attendees or wheelchairs around the table.
PASARR Level II evaluations were not completed for two residents with mental health diagnoses. One resident had a Manic Episode diagnosis added after admission, and another resident had Bipolar Disorder despite a PASARR Level I that did not identify mental health diagnoses. The SSD and DON both stated each resident should have had a new resident review when the diagnosis was identified.
Failure to Obtain Informed Consent for Bed Rail Use: The facility did not document review of the risks and benefits or obtain informed consent before placing 1/4 side rails on two residents. Both residents had orders for bed rail use, and chart review found no consent documentation; the DON confirmed the missing consents, and the ADM and RDO stated they were unaware informed consent was required before use.
Incomplete ADL Bathing Documentation: A resident who required substantial/maximal assistance with bathing had no bath documentation for several scheduled bath days, even though the assigned CNA stated she provided the baths. The CNA confirmed the baths were not charted, and the DON stated that any bath provided should have been documented in the resident's ADL-bathing record.
Failure to Support Resident Choice for Sewing Activity: A resident with Depressive Disorder, mild cognitive impairment, and no UE/LE impairment wanted to sew, but was told she could not have a sewing machine because it was not safe. The resident and her daughter reported sewing had always been a major part of her life, while the AD knew of her preference and PT/COTA said she could safely use a sewing machine with supervision. Administration stated a sewing machine would not be safe for any resident and denied awareness of the request.
Failure to Timely Transmit MDS Assessment: A resident’s discharge MDS was completed but not transmitted within the required timeframe. An LPN confirmed she was responsible for entering MDS assessments and acknowledged the assessment was sent late, and the DON also verified the delay.
A resident with documented pain diagnoses had an MDS that incorrectly coded PRN pain medication use and opioid use as No. The MAR showed repeated PRN Norco administration, and an LPN and the DON confirmed the resident was receiving the opioid and that the MDS coding was inaccurate.
Failure to prime insulin pen needles before insulin administration was observed for two residents. An LPN administered ordered insulin doses using pen needles without first priming them, despite manufacturer guidance and staff acknowledgment that the needles should be primed with two units before the dose is given. One resident was receiving Regular Insulin for sliding-scale coverage based on a BG of 219 mg/dL, and another resident was receiving scheduled Insulin Lispro.
Resident food preferences not honored during meal service. A resident with DM2 on a low concentrated sweets diet with extra portions was repeatedly served items that did not match her documented preferences, including non-sugar-free juice, rice, whole milk, and missing extra vegetables. The dietary manager confirmed the resident should not have received juice, milk, or rice and should have received extra vegetables, and the ADM confirmed resident food preferences should always be honored.
Failure to maintain an infection prevention and control program occurred when two LPNs applied insulin pen needles without sanitizing the pen stoppers before administering Insulin Lispro to two residents. Manufacturer instructions required wiping the rubber seal with an alcohol swab, and both LPNs confirmed they did not perform this step. The DON stated insulin pen stoppers should always be sanitized before needle application.
Failure to provide foot care and podiatry services for a resident with DM. A resident with Type 2 DM and moderate cognitive impairment had abnormally thickened toenails and reported discomfort when sheets touched her toes and when wearing shoes. She said she had requested podiatry care for months, but the chart had no podiatry referral or podiatrist nail care documentation, and staff could not confirm the request had been processed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited when an area of the facility was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and supervision protocols did not sufficiently minimize accident risks.
The facility did not manage its operations to ensure effective and efficient use of resources, as required by regulatory standards.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required. Surveyors found no evidence of procedures or steps outlining how these quality assurance processes are implemented.
A resident with Alzheimer's Disease and a history of falls, who was care planned and ordered to have two fall mats at the bedside, was found to have only one mat in place during multiple observations. Staff interviews confirmed the lack of awareness or implementation of the second fall mat, despite clear care plan and physician orders.
A resident with Alzheimer's and Dementia was subjected to verbal abuse by two CNAs, as captured on video footage. The CNAs yelled and chastised the resident during care routines, leading to a deficiency in the facility's abuse prevention policy. The abuse was reported by the resident's representative, and the facility's administrator confirmed the abuse after reviewing the footage, resulting in the termination of the involved CNAs.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in their documented status. A resident's MDS inaccurately indicated antibiotic use, another's failed to reflect poor oral hygiene, a third's omitted a serious mental illness diagnosis, and a fourth's discharge status was incorrectly coded. These errors were confirmed by facility staff during interviews.
The facility failed to store food properly in the freezer, with several items found in unsealed bags and open boxes, contrary to professional standards. This was confirmed by staff interviews, highlighting a breach in the facility's policy for frozen food storage, potentially affecting 157 residents.
A resident's medication was left unattended at the bedside by an LPN, contrary to the facility's policy. The resident, who was cognitively intact, confirmed the pills were his prescribed aspirin. The LPN and DON acknowledged the error, emphasizing that medications should not be left unattended.
A cognitively intact resident, requiring substantial assistance for transfers, was denied her request to be assisted out of bed after incontinence care. The CNA, uncomfortable with transferring the resident alone, did not seek help, leading to a failure in respecting the resident's right to choose when to get in and out of bed.
Failure to Use Facial Hair Restraint During Meal Service
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food safety when a staff member plating breakfast on the serving line had a mustache and beard without a facial hair restraint. During observation of the breakfast meal service in the kitchen, S4CK was seen serving food from the steam table without wearing a facial hair restraint. S3DM observed S4CK on the serving line and stated he should have had on a facial hair restraint. S1ADM later stated that dietary staff with facial hair should wear a facial hair restraint while preparing and serving food.
Pest Control Failure in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep roaches out of the kitchen. The facility’s policy stated that each facility would have an effective pest control plan in place with resident safety as the top priority and contingency plans if active pest activity was identified. The maintenance log documented roaches in the kitchen on the serving table, and during lunch service observation, a hole was seen in the caulk between the cinderblock wall and the steam table. During the kitchen observation, multiple roaches were seen coming from the hole onto the steam table and toward uncovered food on the steam table. Staff killed several of the roaches as they appeared. A staff member confirmed the bugs were roaches crawling on the steam table with uncovered food, another staff member stated he had seen roaches on the steam table before, and a pest control representative confirmed there was a roach infestation behind the kitchen steam table in the same area identified earlier in the year. The facility administrator confirmed it was not sanitary to have roaches by food.
Resident Council Lacked Private Meeting Space
Penalty
Summary
The facility failed to ensure the resident group had a private space large enough for all residents who wanted to attend resident council meetings. Resident council meeting minutes from May 2025 through August 2025 showed attendance ranging from 9 to 15 residents, and the August 2025 minutes noted residents were wondering what was going on with the enclosed area. During a resident council meeting held in the facility cafe, residents #41, #56, #80, #81, and #156 attended while the glass doors to the dining room were closed and the walls leading to the main hallways had 8-foot openings on each side, leaving the area not enclosed or private. A staff member entered the area and opened the glass door to enter the dining room during the meeting. Residents voiced concerns that the resident council did not have a private space large enough for everyone who wanted to attend, and stated there had been an ongoing issue discussed in prior meetings. The residents reported an attempt to meet in the facility conference room, but it was not large enough for all attendees. Observations of the conference room on two separate days showed it contained a large table with chairs, was not large enough to hold all residents who wished to attend, and could not accommodate wheelchairs around the table. The S8AD confirmed the concern was about needing a private space large enough for everyone, stated the issue had been brought up multiple times, and confirmed there was not a private space large enough for all residents who wanted to attend resident council meetings. The S1ADM stated the cafe was where the resident council met, confirmed it was not a private space, and stated the resident council should have a private space to meet.
PASARR Level II Evaluations Not Completed for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure residents with identified mental health diagnoses were referred for PASARR Level II evaluation and determination for 2 of 3 residents reviewed for PASARR. Resident #5 was admitted with diagnoses including Hereditary and Idiopathic Neuropathy, and the record also showed a diagnosis of Manic Episode with an onset date of 06/01/2023. The record contained no evidence that a PASARR Level II evaluation and determination had been submitted after the Manic Episode diagnosis was identified. Resident #24 was admitted with diagnoses including Depression, and the record also showed a diagnosis of Bipolar Disorder with an onset date of 03/17/2025. His PASARR Level I dated 03/06/2025 did not select any mental health diagnoses, and the record contained no evidence that a PASARR Level II evaluation and determination had been submitted after the Bipolar Disorder diagnosis was identified. During interviews, the SSD and DON both stated that Resident #5 should have had a new resident review when the Manic Episode diagnosis was acquired and that Resident #24 should have had a new resident review when Bipolar Disorder was identified.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the risks and benefits of bed rail use were reviewed with the resident and/or resident representative, and failed to obtain informed consent before installing bed rails for 2 of 3 residents reviewed with bed rails. The facility policy dated 11/25/2014 stated that side rails were to be used as appropriate to resident need and that a physician's order and consent were to be obtained, with the purpose explained to the resident and family before obtaining an order. Resident #3 was admitted with diagnoses including dementia and unspecified mood disorder, and Resident #70 was admitted with diagnoses including dementia, unspecified mood disorder, and hemiplegia with hemiparesis. Review of both residents' clinical records found no documentation of any explanation of the risks and benefits of bed rail use or informed consent from the resident and/or resident representative. Physician orders showed that Resident #3 had an order for 1/4 side rails x 2 as needed for bed mobility on 05/13/2025, and Resident #70 had an order for 1/4 side rails x 2 as needed for bed mobility/positioning on 04/25/2023. Observations on 08/11/2025 through 08/13/2025 showed 1/4 side rails in place at the top of both residents' beds in the upright position. During interviews, the DON confirmed there were no signed informed consents for either resident, and the ADM and RDO stated the facility was unaware that informed consent was required before use of 1/4 side rails.
Incomplete ADL Bathing Documentation
Penalty
Summary
The facility failed to ensure a resident's medical record was complete and accurate by not documenting baths as provided for one resident reviewed for activities of daily living. The resident was admitted with diagnoses including hereditary and idiopathic neuropathy, muscle wasting and atrophy, chronic respiratory failure, heart failure, and chronic pain syndrome. Her quarterly MDS dated 06/11/2025 showed she required substantial/maximal assistance from staff for bathing. Review of the resident's ADL-bathing documentation for August 2025 showed she was scheduled to receive baths on Mondays, Wednesdays, and Fridays, but no bath was documented on 08/04/2025, 08/06/2025, 08/08/2025, or 08/11/2025. A CNA assigned to the resident's hall stated she was responsible for providing the baths on those dates and confirmed she provided them, but also confirmed they were not documented. The DON confirmed that if a bath was provided, it should have been documented on the resident's ADL-bathing documentation.
Failure to Support Resident Choice for Sewing Activity
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for one resident who wanted to participate in sewing activities. The resident was admitted with diagnoses including Depressive Disorder, Mild Cognitive Impairment, and Type 2 Diabetes Mellitus. The most recent MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and documented no impairment of the upper or lower extremities, with supervision needed for transfers. The care plan identified depression and noted the resident expressed feeling down, depressed, or hopeless, with an intervention to encourage participation in daily activities. During the survey, the resident was observed painting watercolors in her room and stated she loved to paint and sew and had sewn since she was young. She reported that she asked the ADM about having a sewing machine and was told she could not have one because it was not safe. The resident's daughter stated the family had inquired about a sewing machine when the resident was first admitted and was told it was not allowed, and that sewing had always been central to the resident's life. Staff interviews showed the activity director had assessed the resident's activity preferences and knew she wanted to sew, PT and COTA stated she would be safe to use a sewing machine with supervision, and CNA staff stated she transferred independently. However, administration stated a sewing machine would not be safe for any resident independently or supervised, and the DON and RDO stated they were not aware of residents requesting a sewing machine.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit Resident #166’s MDS assessment data to the State within the required timeframe for 1 of 1 residents reviewed for resident assessment. Resident #166 was admitted on 02/25/2025 and discharged on 03/14/2025. Review of the discharge MDS with an ARD of 03/14/2025 showed the assessment was completed but not transmitted, with a status of completed but not accepted. An LPN confirmed she was responsible for entering MDS assessments and stated they should be transmitted within 14 days of completion, then verified that Resident #166’s discharge MDS was transmitted on 08/13/2025 and was not sent within the required timeframe. The DON also reviewed the discharge MDS and confirmed the resident was discharged on 03/14/2025 and that the discharge MDS was not transmitted until 08/13/2024, which was not within the required timeframe.
MDS Incorrectly Coded for PRN Pain Medication and Opioid Use
Penalty
Summary
The facility failed to ensure Resident #20’s MDS assessment accurately reflected her status for pain medication use. Resident #20 was admitted with diagnoses that included pain in the left ankle and joints of the left foot and pain unspecified. Her Significant Change MDS with an ARD of 05/21/2025 coded Section J0100.B. Pain Management-Received PRN pain medications or was offered and declined as 0, No, and Section N0415.H. Opioid: is taking as No. Review of the resident’s physician orders showed an order for Norco 5-325 mg, 1 tablet by mouth every 6 hours as needed for pain, with a start date of 07/01/2024. The May 2025 MAR showed the resident received Norco PRN on multiple dates throughout the month. During interviews on 08/13/2025, an LPN and the DON reviewed the MDS and MAR and confirmed the resident was taking PRN Norco at that time and that both MDS sections were coded incorrectly and should have been coded Yes.
Failure to Prime Insulin Pen Needles During Administration
Penalty
Summary
The facility failed to ensure nursing staff followed the manufacturer’s guidelines for insulin pen use by not priming the pen needles before administering insulin to two residents. The report states the insulin pen needle should always be primed with two units of insulin after applying the needle and before drawing up the insulin dose, but this step was not performed during the observed administrations. Resident #106 was admitted on 04/30/2024 and had an order for Regular Insulin 100 unit/mL subcutaneously per sliding scale before meals and at bedtime, with 4 units ordered for a blood glucose level of 200 to 250 mg/dL. During an observation on 08/12/2025, S5LPN administered 4 units of Regular Insulin when the resident’s blood glucose was 219 mg/dL, but did not prime the insulin pen needle. S5LPN later confirmed she did not prime the needle and should have. Resident #114, admitted on 11/24/2021, had an order for 5 units of Insulin Lispro 100 unit/mL subcutaneously three times daily. During an observation on 08/11/2025, S6LPN applied the insulin pen needle, dialed up 5 units, and administered the insulin without priming the needle. S6LPN stated insulin pen needles should always be primed prior to dialing up and administering the ordered dose, and S2DON also stated the needles should always be primed with two units before administering insulin.
Resident food preferences not honored during meal service
Penalty
Summary
The facility failed to ensure that Resident #31’s food preferences were honored. The resident had a diagnosis of Type 2 Diabetes Mellitus and was ordered a low concentrated sweets diet with regular texture, thin liquids, and extra large portions. Her care plan and dietary profile directed staff to maintain her food likes and dislikes and to provide and serve the diet as ordered, including food preferences. Her meal tickets documented preferences such as no juice or punch, no carrots, no scrambled eggs, no sweet potatoes, no white potatoes, and no rice, with extra vegetables requested at lunch and dinner. During observations, Resident #31 was served breakfast trays that included prepackaged juice that was not sugar free, along with items such as boiled eggs, sausages, grits, and a biscuit. At lunch, she was observed receiving trays that included fried chicken breast, green peas, zucchini and tomatoes, a roll, and prepackaged juice that was not sugar free; another lunch tray included meatballs with gravy over rice, mixed vegetables, pineapple cobbler, a roll, prepackaged juice, and whole milk. The resident stated the facility often served her rice, white potatoes, and non-sugar free juice despite these being on her preference list, and that she often did not receive the extra vegetables. A CNA stated meal tickets should be read and trays returned if they did not match resident preferences, and the dietary manager confirmed the resident should not have received juice, milk, or rice and should have received an extra serving of vegetables. The administrator also confirmed residents' food preferences should always be honored.
Failure to Sanitize Insulin Pen Stoppers During Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when nursing staff failed to sanitize insulin pen stoppers before attaching insulin pen needles for two residents. Manufacturer instructions for Insulin Lispro stated to wipe the rubber seal with an alcohol swab before preparing the pen, but this step was not followed during observed medication administration. Resident #86 had an active physician's order for Insulin Lispro 100 unit/mL subcutaneously before meals and at bedtime per sliding scale. During an observation on 08/11/2025 at 10:56 a.m., S7LPN applied the insulin pen needle to the insulin pen without sanitizing the stopper and then administered the insulin; she later confirmed she did not sanitize the stopper. Resident #114 had an active physician's order for Insulin Lispro 100 unit/mL subcutaneously three times daily. During an observation on 08/11/2025 at 9:13 a.m., S6LPN applied the insulin pen needle without sanitizing the stopper and administered the insulin; she later confirmed she did not sanitize the stopper. The DON stated insulin pen stoppers should always be sanitized prior to applying the insulin pen needle.
Failure to Provide Podiatry Foot Care for Resident with Diabetes
Penalty
Summary
Provide appropriate foot care. The facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Type 2 Diabetes Mellitus. Resident #11 was admitted with a diagnosis that included diabetes, and the most recent MDS showed a BIMS of 12, indicating moderate cognitive impairment. The record contained no documentation of a podiatry referral or nail care provided by a podiatrist for the resident. During observation, Resident #11 had abnormally thickened toenails on both big toes and stated she had discomfort when bedsheets touched her toes and when wearing shoes. She stated she had requested to see a podiatrist since January 2025 but had not been seen. The DSS stated the facility used an outside podiatry provider that visited every 3 months and that requests could be made by a resident, nurse, or CNA, but she could not recall when the request was made and found no documentation of the request in the chart or emails. The resident's daughter stated she emailed the DSS after months of the resident requesting podiatry care and was told the resident needed a diagnosis of DM or PVD, which she said the resident did have. The DON stated the DSS should notify the contracted provider to begin services on the next visit.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of its resources. This deficiency was identified based on observations and findings documented by surveyors, indicating that the facility did not meet the required standards for resource management as outlined in regulatory guidelines. No specific details regarding individual residents, staff actions, or particular events leading to this deficiency are provided in the report excerpt.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out QAPI and QAA processes.
Failure to Implement Care Plan Interventions for Fall Prevention
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions for a resident with Alzheimer's Disease and a history of repeated falls. The resident's care plan and physician orders specified the use of two fall mats at the bedside for safety. However, during multiple observations on consecutive days, only one fall mat was present at the resident's bedside. Interviews with facility staff, including an LPN, a CNA, the Assistant Director of Nursing, and the Director of Nursing, confirmed that only one fall mat was in place and that staff were either unaware of the need for a second mat or acknowledged that two mats should have been present according to the care plan and physician orders. The failure to implement the specified intervention was identified for this resident, who had severe cognitive impairment and was at high risk for falls.
Verbal Abuse of Resident by CNAs
Penalty
Summary
The facility failed to protect a resident from verbal abuse by two CNAs, resulting in a deficiency. The resident, who was cognitively impaired with Alzheimer's Disease and Dementia, was unable to communicate effectively and required staff assistance for care. The abuse was captured on video footage, showing the CNAs yelling and chastising the resident in a demeaning and aggressive manner during care routines. The incidents of verbal abuse occurred on multiple occasions, with one CNA yelling at the resident for removing clothing and another CNA using derogatory language related to the resident's incontinence. The resident's representative observed concerning body language through a camera installed in the resident's room, which led to the discovery of the abuse. The representative reported the abuse to the facility's social worker, who confirmed the verbal abuse after reviewing the video footage. The facility's administrator was notified of the allegations and took immediate action by suspending the accused staff members. The administrator confirmed the abuse after reviewing the video footage and subsequently terminated the CNAs involved. The facility's policy on abuse prevention and prohibition was not effectively implemented, leading to the resident being subjected to repeated verbal abuse by staff members.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in their documented status. Resident #72's MDS inaccurately indicated the use of antibiotics, despite physician orders showing no such medication during the look-back period. Resident #84's MDS failed to reflect poor oral hygiene and dental issues, as noted by a dentist and observed during a facility visit. These inaccuracies highlight a lack of proper documentation and assessment of residents' medical and dental conditions. Additionally, Resident #105's MDS did not accurately reflect her PASARR status, omitting her serious mental illness diagnosis, which was previously documented. Resident #162's discharge status was incorrectly coded as a transfer to a short-term general hospital, while nurse's notes indicated a discharge home. These errors were confirmed by facility staff during interviews, indicating a systemic issue in the accurate coding and assessment of residents' statuses.
Improper Food Storage in Facility Freezer
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, potentially affecting 157 residents served from the kitchen. During an initial tour of the kitchen, several items were observed in unsealed bags within open cardboard boxes in the freezer. These items included a 3-ounce plastic bag of breaded fish coquettes, a 2.2-ounce plastic bag of Southern style biscuit dough, a 20.25-pound plastic bag of sopapilla bites, and a 30-pound plastic bag of whole kernel corn. Interviews with staff members confirmed that these items were open and not sealed, which was against the facility's policy for storing frozen food. The policy required that food taken out of original containers be placed in clean, sanitized containers with tight-fitting lids, and that opened boxes with liners be closed and sealed tightly with packing tape.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of medication administration by leaving medications unattended at a resident's bedside. During an observation on July 22, 2024, two small, round, yellow pills were found on the bedside table of a resident who was cognitively intact, as indicated by a BIMS score of 15. The resident confirmed that the pills were his prescribed 81 mg aspirin, which he was supposed to take daily at 8:00 a.m. He stated that the LPN left the medication on his bedside table without waking him, and he intended to take them upon waking. An interview with the LPN confirmed that the pills were indeed the resident's aspirin and acknowledged that they should not have been left unattended. The Director of Nursing also confirmed that medications should not be left at the bedside and that the nurse is expected to observe the resident swallowing the medication. If a resident refuses medication, the nurse should return and dispose of it properly. This incident highlights a breach in the facility's medication administration policy, which mandates that medications should not be left unattended.
Failure to Support Resident's Choice for Bed Transfer
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting a resident's choice of when to get out of bed. The resident, who was cognitively intact with a BIMS score of 14, required substantial assistance for transfers due to conditions including Malignant Neoplasm of Brain Stem, Parkinsonism, Muscle Wasting and Atrophy, Other Lack of Coordination, and Hemiplegia. On the evening of July 22, 2024, the resident requested to be assisted out of bed after receiving incontinence care, but the CNA assigned to her did not fulfill this request. The CNA expressed discomfort in transferring the resident independently and decided to wait for another CNA to assist, but did not seek help or inform anyone to facilitate the transfer. The resident's family later notified the RNC about the incident, who confirmed that the resident should have been assisted out of bed as per her request. The DON also confirmed that residents have the right to choose when to get in and out of bed, indicating a failure in respecting the resident's rights and preferences.
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Illustrative
What surveyors actually found near you
We read the 121 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 Denham Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pines Retirement Center Of Baton Rouge | 4.9 mi | ★★★★★ | 10 | 0 |
| Flannery Oaks Guest House | 5.1 mi | ★★★★★ | 0 | 0 |
| The Woodleigh Of Baton Rouge | 5.2 mi | ★★★★★ | 1 | 0 |
| Capitol House Nursing And Rehab Center | 6.4 mi | ★★★★★ | 0 | 0 |
| Central Guest House Healthcare & Rehabilitation Ce | 6.8 mi | ★★★★★ | 6 | 0 |
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