Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Lakeview Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide individualized behavioral health services for a resident with anxiety, depression, delusional disorder, and psychotic disorder. The resident had persistent anxiety, panic attacks, isolation, and skin picking with sores, while staff and SSD documentation did not accurately reflect her ongoing symptoms. The resident said she was never offered in-room counseling or therapy, and the DON confirmed the facility lacked in-house behavioral health therapy options and did not ensure appropriate follow-up with the psych specialist.
Food service staff failed to label, date, and store food items in accordance with professional standards. Surveyors observed personal items stored in the freezer area, multiple food items with no labels or preparation dates, expired cut tomatoes, and pork chops stored above a covered bowl of diced pears. The S4DM and ADM confirmed that personal items should not have been stored there, meats should have been stored below other foods, and opened or leftover foods should have been labeled with a preparation date.
Failure to notify the provider of a resident’s suicidal statements. A resident with dementia, mood disturbance, anxiety, and schizoaffective disorder was heard saying she wanted to die and no longer wanted to live. Nursing documentation noted the NP and DON were made aware, but the NP record had no documentation of the statement, and interviews showed the DON was not aware and the NP was not informed directly.
Missing Privacy Curtain in Shared Room: Surveyors found that two cognitively intact roommates did not have a privacy curtain attached to the ceiling track in their shared room. Both residents stated they wanted privacy, and CNAs confirmed the room should have a curtain between the beds. The DON also confirmed that all residents have the right to privacy and that a privacy curtain should be in every resident room.
Failure to Refer Resident With New Psychiatric Diagnosis for PASRR Level II Review: A resident acquired a new dx of Schizophrenia, but the facility did not submit a PASRR Resident Review Form for a Level II eval. Staff confirmed there was no Level II PASRR in place, were unaware the form was needed after the new psychiatric dx, and stated there was no process to identify residents with newly acquired psychiatric diagnoses.
A resident with a PEG tube was not administered the correct amount of enteral feeding as ordered, receiving only one can of Diabetisource instead of the prescribed two cans at meals. The nursing staff acknowledged the error after it was highlighted during a survey, indicating a lapse in following the resident's care plan.
A resident with a PEG tube was not administered the correct amount of enteral feeding as per physician's orders, leading to a deficiency in care. The nurse failed to verify the orders and inaccurately documented the administration, providing only one can of Diabetisource instead of the prescribed amount. The DON confirmed the orders were not followed, resulting in a failure to meet professional standards of quality.
A resident with a PEG tube experienced significant weight loss due to the facility's failure to administer the prescribed amount of enteral feedings. Despite orders for more than one can of Diabetisource per feeding, the resident was only receiving one can, leading to a caloric deficit. Staff interviews confirmed the oversight, and the resident's weight loss was attributed to not receiving the correct feeding amounts.
The facility failed to store drugs and biologicals properly, with expired supplements found in a medication room and cart, insulin pens lacking open dates, and loose pills on a cart. An LPN and RN confirmed these issues, and the DON acknowledged the expectations for proper labeling and disposal.
The facility failed to meet food service safety standards, with issues such as undated and improperly stored food items, and staff not wearing beard restraints. Observations included undated opened food, improperly stored raw eggs, and unsealed vegetables. Staff confirmed these deficiencies, affecting 97 residents.
A resident reported feeling scared of her roommate, who made threatening statements. Despite the facility's policy requiring immediate reporting of abuse allegations, staff did not report the incident to administration or the state agency within the required timeframe. The staff were aware of the resident's history of aggressive verbal behavior but did not report it, believing the resident could not physically harm others. The administrator confirmed the behavior as abuse but did not report it, leading to a deficiency in compliance with federal reporting requirements.
A facility failed to complete a comprehensive MDS assessment for a newly admitted resident within the required 14-day timeframe. The resident's admission MDS assessment was still in progress beyond the deadline, as confirmed by staff interviews, indicating a lapse in meeting regulatory requirements for timely assessments.
The facility failed to ensure accurate resident assessments, leading to errors in coding discharge and ostomy status for two residents. One resident was incorrectly coded as discharged to a hospital instead of home, and another was inaccurately coded as having no ostomy despite having a colostomy. These discrepancies were confirmed by staff upon review.
A resident with cognitive impairment exhibited new aggressive behaviors, including threats of violence, which were not documented or reported by staff. The care plan was not updated to reflect these changes, despite staff awareness of the behaviors.
A resident with Cerebral Infarction and Hemiplegia, dependent on staff for ADLs, did not receive scheduled daily morning bed baths over several days due to miscommunication among CNAs regarding shift responsibilities. The Nursing Assignment Binder indicated the resident's need for daily bed baths, but confusion persisted about whether day or night shift staff were responsible, leading to the oversight.
A resident with a history of falls experienced a deficiency in fall prevention measures due to inadequate interventions. Despite being at risk for falls, the facility placed a wedge on the left side of the bed, causing the resident to roll towards a hazardous gap on the right side. Staff confirmed the inappropriate intervention and hazardous bed position, leading to the deficiency.
A nurse in an LTC facility failed to verify and administer the correct amount of enteral feeding for a resident with a PEG tube, consistently providing only one can instead of the prescribed amount. Additionally, the nurse did not adhere to Enhanced Barrier Precautions by failing to wear a gown during feeding tube care. The DON confirmed that the nurse's competencies were not adequately assessed, and there was no process to track nursing skills.
A facility failed to ensure staff used appropriate PPE during care for a resident requiring Enhanced Barrier Precautions. A nurse did not wear a gown while providing tube feeding to a resident with a PEG tube, contrary to the facility's policy requiring gown and gloves for such care. Interviews revealed a misunderstanding of the policy, leading to the deficiency.
A resident with severe cognitive impairment experienced a significant change in condition, including vomiting and feeling unwell. Despite facility policy requiring notification, the resident's representative and family were not informed. Staff interviews confirmed the lack of documentation and notification, indicating a deficiency in the facility's procedures.
A resident with severe cognitive impairment experienced a change in condition, including vomiting, which was not documented by the nursing staff. Despite notifying a nurse practitioner and administering Zofran, these actions were not recorded in the resident's medical records, contrary to the facility's documentation policies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter, as an LPN did not wear a gown during catheter care despite posted instructions. The resident had a urinary tract infection and an indwelling catheter. The LPN was unclear about the gown requirement, and the DON confirmed the lapse in protocol adherence.
The facility failed to ensure accurate MDS assessments for two residents, one with Schizophrenia and another with dementia and fall risk, leading to incorrect documentation of PASRR Level II status and bed alarm usage.
The facility failed to maintain a record of the Level 1 PASRR form in a resident's medical record. The resident, admitted with multiple mental health diagnoses, did not have the required PASRR documentation. Staff interviews confirmed that the corporate outreach team and discharging hospital were responsible for the PASRR, but the facility did not verify its inclusion in the preadmission packet.
A facility failed to provide adequate supervision for a fall-risk resident, resulting in multiple falls. Despite a care plan requiring 2-hourly checks, staff did not adhere to this schedule, as confirmed by video footage and staff interviews.
The facility failed to ensure proper infection control practices by not requiring a CNA to wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions (EBPs) due to a peg tube. The CNA confirmed the oversight, and the DON acknowledged the requirement for appropriate PPE.
Failure to Provide Individualized Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary individualized behavioral health care and services for a resident with multiple mental health diagnoses, including Anxiety Disorder, Delusional Disorder, Depression, Psychotic Disorder, Insomnia, and Generalized Anxiety Disorder. The resident’s annual MDS showed she was cognitively intact with a BIMS of 15, but her record also reflected ongoing psychoactive medication use, including antipsychotic, antianxiety, and antidepressant medications. Her psychiatric specialist notes and NP progress notes documented persistent anxiety, depression, sleep impairment, isolation, panic attacks, and skin picking that caused sores, along with repeated medication changes to address these symptoms. The resident reported that she had lived independently before admission, had previously seen a psychiatrist, and continued to struggle with adjusting to facility life, fear about her health, and worsening anxiety. She stated that when her anxiety was severe, she picked at her skin and caused or worsened sores, and that she had become unwilling to leave her room or participate in therapy, activities, meals, or outside appointments. She also stated she had not been offered behavioral health counseling or therapy in her room, and that she would have participated if such services had been available. Staff interviews confirmed they knew she had ongoing anxiety and depression, that she refused to leave her room, and that she picked at her skin when anxious, but they did not know why she stopped leaving her room or connect the change to her mental health needs. Social services documentation repeatedly indicated the resident was stable with no changes in mood, behavior, social interaction, or rejection of care from August 2024 through April 2026, despite the charted symptoms and medication changes. The social services director stated she was unaware of the resident’s ongoing anxiety, depression, panic attacks, skin picking, and medication adjustments, and acknowledged that the resident’s behavioral health needs had not been identified or addressed through an individualized plan. The DON confirmed the resident should have been followed by the psychiatric specialist after unresolved symptoms and medication changes, but she was not, and the facility did not have in-house behavioral health therapy or counseling options for residents who would not leave the facility for outside treatment.
Kitchen Food Storage and Labeling Deficiency
Penalty
Summary
Food was not prepared, distributed, and served in accordance with professional standards for food service safety because items in the kitchen were not properly labeled, dated, or stored. During a kitchen tour, surveyors observed a personal cup with a lid and straw containing liquid sitting on top of a freezer, a large Styrofoam cup with a lid containing ice with no label and no date, and a small Styrofoam cup with a lid containing dessert with no label and no date. In the cooler, surveyors observed a container of cut tomatoes with a preparation date of 04/06/2026 and a use-by date of 04/12/2026, a container of mixed peanut butter jelly with no preparation date and no use-by date, and a container of tuna salad with no label and no preparation date.
Failure to Notify Provider of Resident’s Suicidal Statements
Penalty
Summary
The facility failed to ensure nursing staff notified the provider when Resident #89 stated she did not want to live anymore. Resident #89 was admitted with diagnoses of unspecified dementia, mood disturbance, anxiety, and schizoaffective disorder, and her quarterly MDS showed a BIMS of 12, indicating moderate cognitive impairment. Nursing notes documented that she was heard in her room saying, “I just want to die already,” and continued to state that she no longer wanted to live after being asked why she felt that way. The record showed that the NP and DON were noted as made aware in the nursing note, but the NP progress notes contained no documentation that Resident #89 made suicidal statements. During interview, the LPN stated she heard the resident say she wanted to die and did not want to live any longer, and said she left a voice message for the on-call provider and wrote the information in a green NP communication binder at the nurse’s station. The DON stated she was not aware of the binder and expected staff to contact her and the NP immediately if the resident was heard saying she did not want to live any longer. The NP stated the on-call provider should have been notified immediately and that, if informed, the resident would have been sent to the hospital for an evaluation.
Missing Privacy Curtain in Shared Room
Penalty
Summary
The facility failed to respect the resident's right to personal privacy for 2 of 25 residents reviewed, Residents #8 and #63, because there was no privacy curtain attached to the ceiling track in their shared room. Resident #8 was admitted on 07/03/2025 and had a Quarterly MDS with a BIMS of 15, indicating cognitive intactness. Resident #63 was admitted on 04/28/2025 and had a Quarterly MDS with a BIMS of 14, also indicating cognitive intactness. Facility census confirmed that Residents #8 and #63 were roommates. During observations on 04/13/2026, 04/14/2026, and 04/15/2026, surveyors repeatedly found that the room had no privacy curtain attached to the track on the ceiling. Resident #8 stated she would like a curtain for privacy in her room, and Resident #63 stated she would like a privacy curtain to separate her space from Resident #8. A CNA confirmed the two residents should have a privacy curtain between the beds to ensure each had personal space, another CNA stated all rooms should have a privacy curtain and was not aware the room did not have one, and the DON confirmed all residents had the right to privacy and a privacy curtain should be in all resident rooms.
Failure to Refer Resident With New Psychiatric Diagnosis for PASRR Level II Review
Penalty
Summary
The facility failed to ensure that a resident with a newly identified psychiatric diagnosis was referred for a PASRR Level II evaluation. Resident #51 was admitted to the facility and later acquired a new diagnosis of Schizophrenia on 03/20/2025. Review of the resident’s most recent PASRR Level 1 form dated 08/08/2022 showed no psychiatric diagnoses, yet the resident’s care plan revised on 10/02/2025 identified a behavioral problem related to Schizophrenia. During interview on 04/14/2026, S6SSD confirmed there was no Level II PASRR for Resident #51 and stated she was unaware that a Resident Review Form should have been submitted after the Schizophrenia diagnosis was acquired. She also confirmed there was no process in place for identifying residents with newly acquired psychiatric diagnoses. On 04/15/2026, S1ADM confirmed that if a resident received a new mental health or psychiatric diagnosis, the facility should submit a Resident Review Form for evaluation and determination for Level II services.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident requiring enteral feeding. The resident, who was admitted with diagnoses including Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was ordered to receive specific amounts of Diabetisource AC via PEG tube at designated times. However, observations and interviews revealed that the resident was not administered the correct amount of enteral feeding as per the physician's orders. Specifically, the resident was supposed to receive two cans of Diabetisource at breakfast, lunch, and dinner, but was only given one can during an observed feeding. Interviews with the nursing staff and the Director of Nursing confirmed that the resident's tube feeding orders had been frequently changed, but at no point was the resident ordered to receive only one can of the formula. The nurse responsible for the feeding admitted to not administering the correct amount until the error was pointed out during the survey. This oversight in following the prescribed feeding regimen indicates a failure in executing the resident's care plan as ordered, potentially impacting the resident's nutritional status.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that a resident received enteral feeding services as outlined in their comprehensive care plan, which did not meet professional standards of quality. Specifically, the facility did not verify the physician's orders prior to the administration of enteral feeding for a resident with a PEG tube. The resident, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was at risk for malnutrition and was on a NPO status. The care plan required the resident to receive specific amounts of Diabetisource at designated times, but these orders were not followed. The nurse, identified as S6RN, failed to administer the correct amount of enteral feeding as per the physician's orders. Despite the orders specifying multiple cans of Diabetisource at each meal, S6RN consistently administered only one can per feeding. This discrepancy was confirmed through interviews and a review of the resident's Medication Administration Records (MARs), which inaccurately documented the administration of the tube feeding as ordered. S6RN admitted to not verifying the tube feeding orders prior to administration and acknowledged the inaccuracies in the documentation. The Director of Nursing (DON) confirmed that the resident was always ordered to receive more than one can of Diabetisource at each meal and that the nurses should have administered the tube feeding as ordered. The DON also confirmed that S6RN should have verified the tube feeding order before administration and should not have documented the administration inaccurately. This failure to adhere to the care plan and physician's orders resulted in a deficiency in the quality of care provided to the resident.
Failure to Administer Prescribed Enteral Feedings
Penalty
Summary
The facility failed to ensure that a resident received the prescribed enteral feedings, leading to significant weight loss. Resident #53, who had a diagnosis of Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was admitted with a PEG tube for nutrition. The resident's clinical records indicated a significant weight loss of 5% or more in the last month and 10% or more in the last six months, despite not being on a physician-prescribed weight loss regimen. The resident was supposed to receive more than one can of Diabetisource per feeding, but observations and interviews revealed that the resident was only receiving one can per feeding, contrary to the physician's orders. Interviews with the staff, including the RN, RD, DON, and NP, confirmed that the resident's tube feeding orders were not followed correctly. The RN admitted to administering only one can of Diabetisource instead of the prescribed amount, which was supposed to be 1.5 cans initially and later increased to two cans per feeding. The RD and NP confirmed that the resident's weight loss could be attributed to not receiving the correct amount of tube feeding, as the resident was receiving 900 kilocalories less than recommended. The DON acknowledged that the nurses should have administered the correct amount of tube feeding as ordered, and the NP confirmed that the incorrect feeding amounts could have contributed to the resident's weight loss.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, leading to several deficiencies. In one of the medication rooms (MR3), eight containers of liquid supplements were found to be expired. This was confirmed by an LPN during an observation. Additionally, a medication cart (MC3) contained expired bottles of Thiamin Vitamin B-1, Aspirin, Melatonin, Magnesium Oxide, and two containers of liquid supplements, all of which were confirmed to be expired by the same LPN. Further deficiencies were observed in another medication cart (MC1), where multiple insulin pens and a multi-dose insulin vial were found without open dates, making it impossible to determine when they were first used. This was confirmed by an RN, who acknowledged that insulin should be marked with an open date. Additionally, the same cart contained several loose pills, which were also confirmed by the RN as inappropriate. The Director of Nursing (DON) stated that she expected nurses to label insulin pens and vials with open or discard dates and confirmed that expired supplements and over-the-counter drugs should be discarded, and no loose pills should be present on medication carts.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several deficiencies were noted, including the lack of proper dating on opened food items such as hot dogs, mustard, mayonnaise, pickles, relish, and ranch dressing. Additionally, sandwiches were found partially covered with torn aluminum foil, and beverages were stored beyond the recommended time frame. In the walk-in cooler, raw eggs were improperly stored above butter and heavy whipping cream, posing a risk of contamination. In the walk-in freezer, cases of chicken and pork loin were stored on the floor, and several bags of vegetables were found opened, unsealed, and undated. The dry storage area also contained bulk containers and partially used food items without identification labels or opened dates. Furthermore, the facility did not ensure that staff with facial hair wore appropriate restraints, as observed when a staff member walked through the food preparation area without a beard restraint. Interviews with staff confirmed these observations and acknowledged the failure to comply with the facility's policies regarding food storage, labeling, and staff attire. These practices had the potential to affect the 97 residents who received nourishment from the facility's kitchen.
Failure to Report Verbal Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of verbal abuse to the State Survey Agency within the required timeframe for a resident who was reviewed for abuse. The facility's policy mandates that any alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. In this case, a resident reported feeling scared of her roommate, who had made threatening statements such as 'I'll shoot you with a gun.' Despite these threats, the staff did not report the incident to the administration or the state agency within the specified timeframe. Interviews with staff revealed that the resident who made the threats had a history of confusion and aggressive verbal behavior, including cursing and making threats to other residents and staff. The staff, including an LPN and CNAs, were aware of these behaviors but did not report them, believing the resident could not physically harm others. The administrator confirmed that such behavior would be considered abuse but did not report it to the state agency, as he believed the resident did not know what she was doing. This inaction led to a deficiency in the facility's compliance with federal requirements for reporting abuse allegations.
Failure to Complete Timely MDS Assessment for New Admission
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe. Resident #195 was admitted to the facility, and their admission MDS assessment, with an Assessment Reference Date (ARD) of 02/25/2025, was still marked as in progress as of 03/10/2025. This was confirmed during an interview with S3MDS, who acknowledged that the assessment had not been completed in the required timeframe. Additionally, S2DON confirmed that the MDS should have been completed within the specified period, indicating a lapse in adhering to the regulatory requirements for timely assessments.
Inaccurate Resident Assessments in Discharge and Ostomy Status
Penalty
Summary
The facility failed to ensure accurate resident assessments, leading to discrepancies in the coding of discharge and ostomy status for two residents. Resident #94 was discharged from the facility on February 15, 2025, and the MDS Discharge Assessment inaccurately indicated a discharge to an acute hospital, while the nurse's notes confirmed the resident was discharged home with family. This error was confirmed by S7MDS upon review of the resident's medical record. Additionally, Resident #22, who was admitted with a medical diagnosis of Colostomy Status, was inaccurately coded in the MDS Quarterly Assessment as having no bowel and bladder appliances, despite having a colostomy. This discrepancy was observed during colostomy care and confirmed by S7MDS upon review of the assessment. S2DON also confirmed that all MDS assessments should have been coded accurately, indicating a failure in the facility's assessment process.
Failure to Update Care Plan for Resident's New Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to reflect new aggressive behaviors. The resident, who was moderately cognitively impaired and had a history of physical and verbal aggressive behaviors, exhibited new threatening behaviors, including making threats of violence with a knife or gun. These behaviors were not documented in the resident's care plan or nurses' notes, and the care plan was not updated to include interventions for these new behaviors. Interviews with staff revealed that the resident's aggressive behaviors were known to some staff members, but they were not reported to administration or documented appropriately. The staff, including CNAs and an LPN, were aware of the resident's verbal threats but did not take the necessary steps to update the care plan or notify the administration. The MDS coordinator and the Director of Nursing confirmed that they were unaware of the new behaviors and acknowledged that the care plan should have been updated to address these changes.
Failure to Provide Scheduled Bed Baths to Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, Resident #47, who was admitted with diagnoses including Cerebral Infarction and Hemiplegia, was dependent on staff for showering and bathing. Despite being scheduled for daily morning bed baths, the resident did not receive these services on multiple consecutive days in March 2025. Interviews with staff revealed a lack of clarity and communication regarding the responsibility for providing bed baths. While the Nursing Assignment Binder indicated that Resident #47 was to receive daily morning bed baths, there was confusion among the CNAs about whether day or night shift staff were responsible for this task. This miscommunication resulted in the resident not receiving the scheduled bed baths, as confirmed by the Director of Nursing and the staff responsible for creating the shower/bed bath schedules.
Inadequate Fall Prevention Measures Lead to Deficiency
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, leading to a deficiency in accident hazard prevention. The resident, who was admitted with diagnoses including cerebral infarction and hemiplegia, was at risk for falls and required maximum assistance for bed mobility. Despite a previous fall from bed, the facility's intervention of placing a wedge on the left side of the bed was inadequate, as it caused the resident to roll to the right, where there was a hazardous gap between the bed and the wall. This gap was identified as an accident hazard, yet no alternative bed positions were attempted to mitigate the risk. Observations and interviews revealed that the resident's bed was positioned diagonally in the room, creating a space on the right side that contributed to the fall. Staff interviews confirmed the inappropriate intervention and the hazardous bed position. The Director of Nursing acknowledged the inadequacy of the intervention, and the Administrator was unaware of the bed's position, confirming that the intervention would not prevent future falls. The facility's failure to address the bed positioning and implement effective fall prevention measures directly led to the deficiency.
Deficiency in Nurse Competency and Adherence to Precautions
Penalty
Summary
The facility failed to ensure that a registered nurse (S6RN) possessed the necessary competencies and skills to care for residents as outlined in their care plans. Specifically, S6RN was unable to verify and administer enteral feedings as ordered by the physician for a resident with a PEG tube. The resident was prescribed more than one can of Diabetisource per feeding, but S6RN consistently administered only one can without verifying the order. This discrepancy was confirmed through interviews and record reviews, revealing that S6RN had never administered the correct amount of tube feeding since the resident began receiving it. Additionally, S6RN failed to adhere to Enhanced Barrier Precautions when providing care to the same resident. Despite the resident being on Enhanced Barrier Precautions, which required the use of gloves and a gown for high-contact activities such as feeding tube care, S6RN did not don a gown during the procedure. This was observed and confirmed during interviews, where S6RN demonstrated a lack of understanding of the precautions required. The Director of Nursing (S2DON) acknowledged that S6RN had not been adequately observed to ensure competency in performing nursing tasks, including verifying tube feeding orders and adhering to Enhanced Barrier Precautions. The facility's policy required that licensed nurses have the specific competencies necessary to care for residents' needs, but S2DON admitted that there was no process in place to track or evaluate nursing skills, and orientation training was primarily verbal without competency evaluations.
Failure to Use Appropriate PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff utilized appropriate personal protective equipment (PPE) during care for a resident requiring Enhanced Barrier Precautions. Specifically, during an observation, a registered nurse (S6RN) did not wear a gown while providing tube feeding to a resident with a percutaneous endoscopic gastrostomy (PEG) tube, despite the facility's policy requiring both gown and gloves for high-contact activities involving indwelling medical devices. The resident, identified as having a gastrostomy status, was admitted to the facility with orders for Enhanced Barrier Precautions due to the presence of the PEG tube. Interviews with the staff revealed a misunderstanding of the facility's policy on Enhanced Barrier Precautions. The registered nurse believed that only hand hygiene and gloves were necessary, while the facility's Infection Preventionist (S2DON) confirmed that the policy required both gown and gloves for care involving indwelling medical devices. This discrepancy in understanding and implementation of the policy led to the deficiency observed during the survey.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify the representative of a resident with severe cognitive impairment about a significant change in the resident's condition. The resident, who was admitted with diagnoses of cerebral infarction due to embolism and cardiomegaly, experienced vomiting and reported not feeling well on a specific date. Despite the facility's policy requiring prompt notification of a resident's representative in such cases, there was no documentation indicating that the representative was informed of the resident's condition change. Interviews with the staff involved revealed that the LPN assigned to the resident on the day of the incident could not recall notifying the resident's representative, and the CNA confirmed reporting the resident's condition to the LPN. The Director of Nursing also confirmed the lack of documentation regarding notification to the resident's representative or family. The resident's representative and family member both confirmed they were not informed of the change in condition, highlighting a deficiency in the facility's adherence to its notification policy.
Failure to Document Resident's Change in Condition and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by professional standards. Specifically, the nursing staff did not document a resident's change in condition, the notification of the provider about this change, or the administration of Zofran, a medication given to the resident. The facility's policy on documentation requires that all pertinent changes in a resident's condition, medication administration, and notifications to physicians be recorded. However, these actions were not documented for the resident in question. The resident, who had severe cognitive impairment and was admitted with diagnoses including cerebral infarction and cardiomegaly, experienced vomiting and a change in condition. Despite the nurse's verbal confirmation of notifying the nurse practitioner and administering Zofran, there was no written record of these actions in the resident's medical records. The Director of Nursing confirmed the lack of documentation and acknowledged that it should have been recorded according to the facility's policies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The facility's policy required the use of gowns and gloves during high-contact resident care activities, such as urinary catheter care, to prevent the transmission of multidrug-resistant organisms. However, during an observation, a Licensed Practical Nurse (LPN) was seen performing urinary catheter care and a dressing change for a resident without wearing a gown, despite the posted EBP signage on the resident's door indicating the necessity of such precautions. The resident involved had been admitted with diagnoses of a urinary tract infection and retention of urine, and their clinical record confirmed the use of an indwelling catheter. The LPN admitted to being unclear about the requirement to wear a gown for catheter care, even after reviewing the EBP instructions. The Director of Nursing (DON) confirmed that the resident was on EBP and acknowledged that the LPN should have worn a gown during the care activities, indicating a lapse in adherence to the facility's infection control protocols.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their Minimum Data Set (MDS) documentation. For one resident with diagnoses including Schizophrenia and Paranoid Schizophrenia, the facility did not correctly code the resident's PASRR Level II status or serious mental illness on the most recent yearly MDS. This was confirmed through interviews with multiple staff members, including the MDS coordinators and the Director of Nursing (DON), who acknowledged the oversight and confirmed that the resident should have been coded correctly in their MDS assessments. Another resident, who had diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and was a fall risk, had a bed alarm in use as per physician orders and staff observations. However, the facility failed to accurately reflect the use of the bed alarm in the resident's annual and quarterly MDS assessments. Interviews with the resident's family member, Certified Nursing Assistants (CNAs), and Licensed Practical Nurse (LPN) confirmed the consistent use of the bed alarm to prevent falls. Despite this, the MDS assessments did not document the bed alarm usage, as directed by the corporate office, which instructed not to code the bed alarm under Section P as it was not considered a restraint. These inaccuracies in the MDS assessments indicate a failure to ensure that residents' assessments accurately reflected their status and needs. The facility's policies on MDS completion and conducting accurate resident assessments were not adhered to, resulting in incomplete and incorrect documentation of the residents' conditions and care requirements.
Failure to Maintain PASRR Documentation for Resident
Penalty
Summary
The facility failed to maintain a record of the Level 1 Preadmission Screening Resident Review (PASRR) form in the resident's medical record for one of the four residents reviewed. Resident #6, who was admitted with diagnoses including Unspecified Dementia with Mood Disturbance, Schizophrenia, Major Depressive Disorder, Anxiety Disorder, and Schizoaffective Disorder, did not have the required PASRR documentation in her clinical record. The absence of this documentation was confirmed during interviews with facility staff, who acknowledged that the preadmission packet received from the corporate outreach team did not include the Level 1 PASRR form. Interviews with the Social Worker (S10SW), Minimum Data Set Coordinator (S3MDS), and Director of Nursing (S2DON) revealed that the corporate outreach team and the discharging hospital were responsible for completing the Level 1 PASRR for non-local admissions. However, the facility did not verify the inclusion of the PASRR form in the preadmission packet for Resident #6. The staff confirmed that without the Level 1 PASRR form, there was no way to ensure that the resident was accurately screened prior to admission.
Failure to Provide Adequate Supervision for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as a fall risk. The resident, who had severe cognitive impairment and required assistance with toileting and transfers, experienced multiple falls. The facility's policy required staff to check on residents every 2 hours, but this was not adhered to for the resident in question. Video footage confirmed that staff did not enter the resident's room for extended periods, and interviews with staff corroborated that the required checks were not performed. The resident's clinical record indicated a history of falls and a care plan that included toileting every 2 hours to prevent falls. Despite this, the resident experienced numerous falls over several months. On a specific night, the assigned CNA admitted to not rounding on the resident every 2 hours due to being busy with other residents and failing to ask for assistance from other staff members. Interviews with various staff members, including the CNA, LPN, and DON, confirmed that the resident was a known fall risk and that the expectation was for staff to round every 2 hours. The facility's video footage further validated that the required checks were not conducted, leading to the deficiency in providing adequate supervision to prevent falls for the resident.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. Specifically, the facility did not ensure that a Certified Nursing Assistant (CNA) wore proper Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBPs). The CNA was observed performing incontinent care without wearing a gown, despite the resident being on EBPs due to having a peg tube and being at increased risk of multidrug-resistant organism (MDRO) acquisition. The deficiency was identified during an observation and interview process. The CNA confirmed that she did not wear a gown during the incontinent care of the resident, who was admitted with diagnoses including Congenital Stenosis and Stricture of Esophagus and was care planned for peg tube feeding. The Director of Nursing (DON) also confirmed that direct care staff should wear appropriate PPE, including a gown, when performing incontinent care on a resident with a peg tube. This failure to adhere to the facility's policy on EBPs was noted as a deficiency in the infection prevention and control program.
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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.
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Nursing homes near New Roads
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pointe Coupee Healthcare | 0.7 mi | ★★★★★ | 3 | 2 |
| St. Francisville Nursing And Rehab, Llc | 14.6 mi | ★★★★★ | 2 | 0 |
| River Oaks Nursing & Rehabilitation Center Llc | 19.1 mi | ★★★★★ | 2 | 0 |
| Grace Nursing Home | 19.5 mi | ★★★★★ | 4 | 0 |
| The Lodge At Lane | 19.6 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.