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 St. Margaret's Daughters Home during CMS and state inspections, most recent first.
Failure to Individualize Behavioral Health Care Plan: A resident with agitation, verbal aggression, and loud outbursts had repeated behavioral issues documented in psych, psychosocial, and nursing notes, including distress when needs were not met right away. The care plan did not address his behaviors, cultural background from Honduras, preferences, or refusal of outside psychiatric services, and the ADM and DON confirmed these items were not care planned.
Surveyors found multiple unsecured hazardous chemicals accessible to residents in several areas, including a resident's room, dining room, and salon, with staff confirming these items should have been secured. Additionally, a resident with a history of falls who required two-person assistance for transfers was transferred by a single CNA, resulting in a fall, contrary to the resident's care plan.
Multiple black flying insects were repeatedly observed in the kitchen and dry storage areas, including inside a bottle of vinegar with an unsecured cap. The Dietary Manager confirmed the presence and increase of insects but did not notify administration or pest control, and the DON was unaware of the kitchen infestation. The administrator acknowledged the insects should not have been present and that staff failed to report the issue as required.
Unlocked Medication Storage Room: An LPN left Medication Storage Room a unlocked and unattended, and surveyors observed that medications stored in the room were accessible to residents and unauthorized staff. The DON confirmed the room should not have been left unlocked and unattended.
Unsanitary ice machine, improperly stored food, and missing hair restraints during food handling: The facility had residue and a black substance inside the ice machine, multiple refrigerator and freezer items were opened, unlabeled, and undated, and both a Dietary Aide and the DM were observed assembling food without hair restraints. The DM, DON, and Administrator acknowledged the issues.
Resident records containing PHI were found in a cardboard box under a countertop in a common area near the kitchen. An LPN, ADON, DON, and Administrator confirmed the box held original facility documents such as High Risk Meeting sheets, 24-hour reports, controlled drug records, and pharmacy receipts with resident-specific medical information, including medication details, physician information, ADL status, and oxygen orders.
A resident with moderate cognitive impairment was found with Voltaren gel at their bedside on multiple occasions, despite not being assessed or care planned for self-administration of medications. Facility records showed no physician order for self-administration or for Voltaren gel, and staff confirmed the resident should not have had access to the medication.
A resident with a history of falls experienced two witnessed falls when staff failed to update the care plan after the first incident and did not follow the care plan's requirement for two-person assistance during a transfer, resulting in a second fall. The DON and MDS nurse confirmed that the care plan was not revised or properly implemented as required.
The facility failed to notify the state's LTC Ombudsman in writing when a resident was discharged. Records showed the resident left the facility, but the transfer log only reflected ombudsman notifications for transfers, not discharges. Social Services stated she was unaware of the written notice requirement, and the Administrator confirmed the ombudsman was not notified.
The facility failed to complete a Level II PASRR screening for a resident admitted with Major Depressive Disorder and Bipolar Disorder. The resident's Level 1 PASRR identified a mental disorder and documented the need for care indefinitely, but the chart showed no evidence of a Level II screen. The SSD stated the facility did not submit a request or ensure the screening was completed, and the DON said she was not aware a Level II PASRR was needed.
The facility did not submit required payroll information for direct care staffing for a specific quarter in 2024. A review of the PBJ Staffing Data Report showed a lack of submission for the period, with no documented evidence provided by the facility to confirm compliance.
A facility's medication error rate exceeded 5%, with errors involving two residents. One resident, cognitively intact, was prescribed Ferrous Gluconate 240 mg but was mistakenly given Ferrous Sulfate 325 mg, which they refused. Another resident with cognitive deficits was prescribed Ferrous Gluconate 324 mg but was given 240 mg instead. Both errors were acknowledged by the LPNs involved.
The facility failed to ensure proper hand hygiene during incontinence care for two residents, with CNAs not changing gloves or performing hand hygiene as required. Additionally, clean and dirty laundry were not properly separated in a laundry room, with unlabeled baskets and improper placement of soiled linen and clean laundry. Staff acknowledged these lapses, and the DON confirmed the failure to adhere to infection control standards.
A facility failed to perform a weekly skin assessment for a resident at high risk for pressure ulcers, as required by physician orders and facility policy. The resident, with a Braden Scale score indicating very high risk, did not receive the assessment on the specified date. Interviews with staff confirmed the oversight, and no documentation was found to indicate the assessment was completed.
A facility failed to accurately document a resident's medication administration record for Ferrous Gluconate 324 mg, as required by their policy. An LPN documented administering the medication on several occasions but later confirmed she did not administer it on those dates. This inaccuracy was confirmed by the DON, highlighting discrepancies in the resident's medication records.
The facility failed to maintain a clean and safe environment for residents, with two residents' rooms found unclean and three residents' equipment in disrepair. Observations revealed dried substances and food debris in rooms, and damaged rolling bedside tables. An LPN and the administrator confirmed these deficiencies.
The facility failed to ensure accurate documentation in Physician Progress Notes for two residents. An NP photocopied previous notes and reused them for subsequent visits, resulting in identical assessments across multiple visits. This practice was against facility policy, as confirmed by the DON, Administrator, and COO.
The facility did not conduct a performance review for a CNA within the last 12 months. The CNA's personnel file, with a hire date of 10/17/2018, showed no evidence of a recent review, and the COO confirmed the absence of such documentation.
The facility failed to prevent expired food from being available for consumption, maintain kitchen sanitation, and document temperature checks for food storage and preparation. Expired items like sauces and milk were found, and the kitchen had unsanitary conditions, including dirty equipment and leaks. Staff interviews confirmed the absence of temperature checks and documentation, which was acknowledged by the DON and Administrator.
The facility failed to document its Water Management Program for Legionella prevention and did not track or trend infections to identify clusters. Interviews revealed no evidence of monitoring water temperatures or other program components. Infection Logs for several months listed various infections, but no documentation showed plotting these infections to identify trends.
The facility failed to document education and refusal of influenza and pneumococcal vaccinations for four residents. The Quality Director noted verbal inquiries were made, but no proof of refusals or education was documented. Additionally, outdated educational materials were used, and the DON had no further information to address the deficiency.
The facility did not ensure CNAs received 12 hours of annual in-service education, as evidenced by a lack of documentation in personnel files for three CNAs. The Chief Operating Officer confirmed the absence of monitoring for the completion of these training hours.
The facility failed to protect residents from psychosocial abuse by a CNA, who made disparaging remarks and handled residents roughly, causing emotional distress and physical pain. The incidents were reported by three residents and corroborated by staff interviews, leading to the CNA's termination.
Failure to Individualize Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop an individualized behavioral health care plan to address one resident’s behavioral health needs. Resident #1’s psychiatric consult note documented increased agitation, verbal aggression when needs were not met right away, defensiveness and irritability during conversation, and statements about talking loudly so people would understand him. The note also recorded that he said he had been a slave in Honduras and did not like being disrespected or labeled as something he was not. Nursing notes documented multiple dates when behaviors were present, including an incident in which he was observed yelling in the hallway for a pillowcase and continued to yell and act irate even after staff promptly provided it. The resident’s psychosocial note also documented increased agitation when his needs or preferences were not met immediately. Review of the care plan showed no plan addressing his behaviors, cultural background and preferences, or refusal of outside services. Staff interviews confirmed he was verbally aggressive, difficult to calm when he did not get his way, and had loud outbursts when things did not go as he wanted. Social services and nursing staff stated he refused all therapeutic psychiatric services except the consulting psychiatric group, and the administrator and DON confirmed that his behaviors, cultural background, and refusal of services should have been care planned but were not.
Unsecured Hazardous Chemicals and Inadequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to ensure that hazardous chemicals were not accessible to residents and did not provide adequate supervision to prevent accidents. Multiple unsecured chemicals were observed in various locations, including a spray bottle of floor cleaner on a housekeeper’s cart, plant food/fertilizer in a dining room, a spray bottle of sanitizer in an unlocked cabinet, and cleaning chemicals in an unsecured salon room. Additionally, a resident with sensory and perception alterations related to vision was found to have two cans of aerosolized insecticide in her room, which staff were unaware of and acknowledged should not have been accessible. Staff interviews confirmed that these chemicals should have been secured and not available to residents. The facility also failed to provide sufficient supervision to prevent a fall for a resident with a history of falls who required maximal assistance from two staff for transfers. Despite this care plan, a CNA attempted to transfer the resident alone, resulting in a witnessed fall. The DON confirmed that the resident’s fall care plan, which required two-person assistance for transfers, was not implemented at the time of the incident.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
Surveyors observed multiple black flying insects present in the facility's kitchen and dry storage room on several occasions. On two consecutive days, black flying insects were seen in the kitchen's dry storage area and around shelving units. Additionally, a gallon bottle of distilled vinegar was found with its cap ajar, containing several dead black insects floating in the liquid. These findings were confirmed by the Dietary Manager, who acknowledged the presence of the insects in both the dry storage room and the kitchen, and noted an increase in their number. Interviews with facility staff revealed a lack of timely communication and response regarding the pest issue. The Dietary Manager did not notify the facility administrator or pest control when the insects returned to the kitchen. The Director of Nursing was aware of the insects in the facility but was not informed that they were present in the kitchen. The facility administrator confirmed that the insects should not have been present and that it was the Dietary Manager's responsibility to monitor and report such issues. No residents or their medical conditions were mentioned in relation to this deficiency.
Unlocked Medication Storage Room
Penalty
Summary
The facility failed to ensure that Medication Storage Room a was not accessible to residents and unauthorized staff. During observation on 08/18/2025 at 11:03 AM, the door to Medication Storage Room a was found unlocked and unattended, and medications stored in the room were accessible. In an interview at 11:05 AM, an LPN confirmed the room was unlocked and unattended and stated that she had left it unlocked. Later, at 11:30 AM, the DON stated that Medication Storage Room a should not have been left unlocked and unattended.
Unsanitary ice machine, improperly stored food, and missing hair restraints during food handling
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary manner. During observation, pink colored residue was seen on the inside top corner of the ice machine, along with a black colored substance on the inside corner. The Dietary Manager confirmed the ice machine was not maintained in a sanitary manner, and the DON and Administrator later acknowledged the same condition. The facility also failed to ensure food stored in the refrigerator and freezer was properly covered, labeled, and dated. Multiple items were observed opened, unlabeled, undated, and available for use, including partially brown shredded lettuce, a fourth of a watermelon, an opened box of corn dogs, cilantro, tortillas, swiss cheese, a half of a red cut onion, several containers of cooked foods such as soup-like liquid, pureed sweet potatoes, gravy, pureed ham, canned vegetables, pork sausage, baked chicken, and packages of sliced and diced ham. In addition, dietary staff did not wear proper hair restraints while handling and assembling food; a Dietary Aide was observed assembling food with hair not restrained, and the Dietary Manager was later observed doing the same. The Dietary Manager stated she should have restrained her hair, and the Administrator stated the Dietary Aide should have restrained their hair while assembling residents' food.
Resident Records Left in Common Area
Penalty
Summary
The facility failed to ensure medical documents containing resident health information were stored in a confidential manner for 6 of 6 residents identified in the report. During observation, a cardboard box filled with resident records was found under a countertop in a common area near the kitchen on Hall B. An LPN and the ADON reviewed the box and confirmed it contained original copies of the facility's High Risk Meeting sheets, 24-hour Reports, Resident Controlled Drug Record Forms, and Pharmacy Receipts, all of which contained resident-specific medical information that should have been kept confidential. Further review of the box revealed multiple documents with resident-identifiable information, including Resident #65's Controlled Drug Receipt/Record/Disposition Forms for Hydrocodone and Lorazepam showing the date dispensed, drug strength, amount administered, and unused medication amount; a pharmacy Shipping Manifest documenting delivery or disposition of Resident #97's Hydralazine and Resident #13's Citalopram; an untitled document listing Resident #2, Resident #92, and Resident #97's prescribed antibiotic; and a 24-Hour Report for Resident #106 that included medication received, physician information, activities of daily living capabilities, and oxygen orders. The DON and Administrator both confirmed the records should not have been placed in a common area accessible to unauthorized personnel and residents.
Failure to Assess Resident Before Allowing Access to Medication at Bedside
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11, was found to have a tube of Voltaren gel at their bedside on multiple occasions. Review of the resident's records showed no physician order for self-administration of medications, no order for Voltaren gel, and no care plan addressing self-administration or bedside access to medications. The resident's electronic medication administration record documented that all medications were to be administered by facility staff. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident had not been assessed or care planned to self-administer medications and should not have had access to Voltaren gel. Despite this, the medication was observed at the resident's bedside on two separate days, indicating a failure to ensure the resident was properly assessed for safe self-administration prior to having access to the medication.
Failure to Revise and Implement Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise and implement a resident's care plan following a witnessed fall. According to the facility's Accidents/Incidents Policy, the charge nurse or nursing supervisor is required to initiate a care plan change to ensure the resident's welfare and safety before the end of the shift. However, after a resident with a history of falls experienced a witnessed fall with no injury, the care plan was not updated with new goals or interventions. Both the Director of Nursing and the MDS Nurse confirmed that the care plan was not revised as required after the incident. Additionally, the facility did not ensure that existing fall care plan interventions were implemented. The resident's Activities of Daily Living care plan specified the need for maximal assistance and required two staff members for transfers. Despite this, a CNA attempted to transfer the resident alone, resulting in another witnessed fall. The Director of Nursing confirmed that the care plan, which required two staff for transfers, was not followed during this incident.
Failure to Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state's LTC Ombudsman in writing when Resident #104 was discharged from the facility. Record review showed Resident #104 was discharged on 07/18/2025, and a nurse's note documented the discharge at 10:00 AM that day. Review of the facility's Emergency Transfer Log for June and July 2025 showed the facility only notified the state's LTC Ombudsman of transfers, and there was no evidence that Resident #104's discharge was communicated to the ombudsman. During interviews, the Social Services staff member stated she was unaware that written notification was required for any resident discharge or transfer and confirmed she had not notified the ombudsman of Resident #104's discharge. The assigned state's LTC Ombudsman also stated she had not received a written discharge notice for Resident #104, and the Administrator confirmed the ombudsman was not notified as required.
Failure to Complete PASRR Level II Screening
Penalty
Summary
The facility failed to ensure a Level II PASRR screening was completed for Resident #46, who was admitted with diagnoses including Major Depressive Disorder and Bipolar Disorder. The resident did not have a diagnosis of dementia and/or Alzheimer's disease, and the Level 1 PASRR dated 11/12/2024 identified a mental disorder of Major Depressive Disorder and documented that the physician expected the resident to need care indefinitely. Review of the resident's EMR and physical chart found no evidence that a Level II PASRR was completed. In interviews, the Social Service Designee stated the facility had not submitted a request and had not ensured a PASRR Level II screen was completed prior to or after the resident's admission, and the DON stated the resident did not have a completed PASRR Level II screening and she was not aware one was needed.
Failure to Submit Payroll Information for Direct Care Staffing
Penalty
Summary
The facility failed to electronically submit payroll information for direct care staffing as required by CMS. A review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 4 2024 revealed that the facility did not submit staffing data for the period from July 1 to September 30, 2024. There was no documented evidence provided by the facility to show that the PBJ Staffing Data for this quarter was submitted as required.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.66% during a survey. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident #3, who was cognitively intact with a BIMS score of 15, was prescribed Ferrous Gluconate 240 mg daily for Iron Deficiency Anemia. However, an LPN attempted to administer Ferrous Sulfate 325 mg instead, which was refused by the resident. The LPN acknowledged the error, and the pharmacist confirmed that such a substitution should not occur without physician approval. Resident #R5, diagnosed with Anemia, Cognitive Deficit, and Dementia, was prescribed Ferrous Gluconate 324 mg daily. An LPN attempted to administer a 240 mg dose instead. The LPN recognized the mistake, and the DON confirmed the error in dosage. These incidents contributed to the facility's medication error rate exceeding the acceptable threshold, highlighting lapses in medication administration accuracy.
Infection Control Deficiencies in Hand Hygiene and Laundry Management
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by Certified Nursing Assistants (CNAs) during incontinence care for two residents. One resident, who was always incontinent of bowel and bladder and dependent on staff for toileting hygiene, was observed receiving care from a CNA who did not change gloves or perform hand hygiene after removing a soiled brief and before placing a clean one. The CNA also touched the resident's pillow and bed linens with the same gloves used during incontinence care. Another resident, who was incontinent and had a urinary tract infection, received peri-care from a CNA who did not perform hand hygiene before putting on gloves, did not change gloves or perform hand hygiene after completing peri-care, and did not perform hand hygiene before leaving the room. Both CNAs acknowledged their failure to follow proper hand hygiene protocols, and the Director of Nursing confirmed these lapses in infection control standards. Additionally, the facility failed to maintain separation between clean and dirty laundry in one of the observed laundry rooms. Observations revealed unlabeled baskets containing both clean and dirty laundry placed next to each other on the floor. A housekeeper and a CNA confirmed that the laundry was not labeled or separated as required. Further observations showed soiled linen placed in a handwashing sink and clean laundry directly on top of a dryer. Staff interviews confirmed that these practices were not in accordance with proper infection control procedures, as dirty linen should not be placed in handwashing sinks, and clean laundry should not be left on surfaces where contamination could occur.
Failure to Conduct Weekly Skin Assessment for High-Risk Resident
Penalty
Summary
The facility failed to adhere to a physician's order to conduct a weekly skin assessment for a resident identified as being at high risk for pressure ulcers. According to the facility's Wound Prevention and Skin Care policies, residents with a Braden Scale score greater than 12 are considered at risk and require weekly skin checks by a licensed nurse, which should be documented in the resident's Electronic Medical Record (EMR). Resident #2, who had a Braden Scale score of 8.0 indicating a very high risk for skin breakdown, did not receive the required skin assessment on 12/11/2024 as ordered by the physician. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the weekly skin assessment for Resident #2 was not completed on the specified date. The absence of documented evidence in the resident's assessment report further corroborated this oversight. The failure to perform the skin assessment as ordered represents a deficiency in the facility's care for residents at risk of developing pressure ulcers.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's medication administration record, specifically for a resident prescribed Ferrous Gluconate 324 mg to be taken daily with breakfast. The facility's Liberalized Medication policy requires that the date, time, dosage, and medication administered be recorded by the individual administering the medication. However, the Medication Administration History Report showed that an LPN documented administering the medication on several dates, but later confirmed that she did not actually administer the medication on those dates. This discrepancy was confirmed by the Director of Nursing, indicating inaccuracies in the medication administration records for the resident.
Deficiencies in Cleanliness and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations and interviews. Two residents' rooms and equipment were found to be unclean. Specifically, one resident's room had large areas of a dried tan substance on the floor and tube feeding pole, which was confirmed by an LPN to be unclean. Another resident's room had small and large pieces of food and splatters of dried liquids on the floor, side rail, bed frame, and rolling bedside table. The administrator confirmed that the room and equipment were dirty and should have been kept clean. Additionally, the facility did not ensure that residents' equipment was in good repair. Observations revealed that the rolling bedside tables of three residents had peeled and broken edges. The administrator confirmed that these tables were damaged and should have been replaced. These deficiencies indicate a failure to provide a safe, clean, and comfortable environment for the residents.
Inaccurate Documentation in Physician Progress Notes
Penalty
Summary
The facility failed to ensure complete and accurate documentation for Physician Progress Notes for two residents. For one resident, the Nurse Practitioner (NP) documented progress notes on several occasions, but the notes were identical, with the chief complaint, physical exam, diagnosis, problem list, and plan remaining unchanged across multiple visits. These notes were photocopies of an earlier note with only the date altered. Similarly, for another resident, the NP documented progress notes that were also identical across several visits, with vital signs, chief complaint, physical exam, laboratory results, diagnosis, problem list, and plan remaining the same. These notes were also photocopies of a previous note with the date changed. During interviews, the NP admitted to photocopying previous progress notes and using them for subsequent assessments, acknowledging that the assessments, including vital signs and physical exams, would not have been exactly the same for each visit. The Director of Nursing and the Administrator confirmed that it was not the facility's policy to photocopy previous progress notes and use them for future assessments, nor to document previous assessments as current and accurate. The Chief Operating Officer also confirmed that this practice was against facility policy.
Lack of Performance Review for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had a performance review within the last 12 months. Specifically, the personnel file of a CNA, hired on 10/17/2018, lacked documented evidence of a performance review being completed within the past year. During an interview, the Chief Operating Officer confirmed that there was no documented evidence of a performance review for this CNA.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that expired food was not available for resident consumption, maintain the kitchen in a sanitary manner, and document temperature checks for food storage and preparation equipment. Observations revealed several expired food items, including garlic parmesan wing sauce, ground ginger, vanilla syrup, cinnamon sauce, and regular milk, which were available for use. Both the Dietary Manager and the Administrator acknowledged that expired food should not have been available in the kitchen or food pantry. Additionally, the facility's kitchen was found to be unsanitary, with issues such as fuzzy, shriveled oranges, brown liquid substances on the floor, caked-on substances on the deep fryer, and dirty pots and pans. The steam table contained cloudy yellow water, and the handwashing sink had a leak. Furthermore, there was no documented evidence of temperature checks for the steam tables and refrigerator/freezers, as confirmed by interviews with staff members. The Director of Nursing and the Administrator acknowledged the lack of temperature checks and documentation.
Deficiencies in Water Management and Infection Tracking
Penalty
Summary
The facility failed to maintain documented evidence of its Water Management Program for Legionella prevention. The program, dated February 2024, outlined requirements such as maintaining water temperatures outside the ideal range for Legionella growth, preventing water stagnation, ensuring adequate disinfection, and maintaining plumbing to prevent conditions conducive to Legionella. However, interviews with the Quality Director, Director of Nursing, and Administrator revealed that the facility did not have documentation of monitoring water temperatures or any other components of the Water Management Program. Additionally, the facility did not accurately track and trend infections to identify clusters or trends. The Infection Logs for May, June, and July 2024 listed various infections among residents, including conjunctivitis, respiratory infections, urinary tract infections, and skin infections. Despite this, the facility's Tracking and Trending Maps for these months showed no documented evidence of plotting these infections to identify potential clusters or trends. Interviews with the Quality Director and Director of Nursing confirmed the lack of appropriate tracking and trending of infections.
Lack of Documentation for Vaccination Refusals and Education
Penalty
Summary
The facility failed to ensure that the medical records of four residents contained documentation of education and refusal of influenza and pneumococcal vaccinations. Specifically, the records for these residents did not have documented evidence of refusal or consent for the vaccinations. The facility's spreadsheet indicated that these residents had refused the vaccinations, but there was no proof of refusals or education provided prior to the date of the vaccination review. The Quality Director admitted to verbally asking the residents about vaccinations and documenting the outcomes on the facility's spreadsheet, but acknowledged the lack of documentation for refusals or education. Additionally, the facility did not provide current literature for educating residents on the risks and benefits of the vaccinations, as the education materials used were from 2022. The Director of Nursing confirmed that there was no further information available to address the areas of deficient practice.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service education annually. This deficiency was identified through a review of personnel files for three CNAs, all of whom lacked documented evidence of completing the necessary in-service hours. Specifically, the personnel files for CNAs hired on 10/17/2018, 03/15/2019, and 11/10/2020 showed no documentation of the required training. During an interview, the Chief Operating Officer acknowledged the absence of documentation and admitted that the facility had not monitored the completion of the annual in-service training hours.
Failure to Protect Residents from Psychosocial Abuse
Penalty
Summary
The facility failed to protect the residents' rights to be free from psychosocial abuse by a Certified Nursing Assistant (CNA). This deficiency was identified for three residents who reported abusive behavior by S5CNA. Resident #1, who was cognitively intact, reported being told by S5CNA that she was in the nursing home because her family did not love her, which left her visibly upset and crying. Resident #2, who had moderate cognitive impairment, reported that S5CNA disregarded her request to be careful with her arthritic knee during incontinence care, causing increased pain. Resident #2 also reported that S5CNA responded dismissively when she mentioned that God was watching her. Resident #3, who had mild cognitive impairment, reported that S5CNA was rough when turning him in bed and told him he could turn himself, which he could not do, leading him to wait for the day shift CNA to get out of bed. Interviews with other staff members corroborated the residents' reports. S2CNA discovered Resident #1 crying and upset during morning rounds, and S3LPN and S4LPN both reported that residents had complained about S5CNA's behavior during the night shift. The facility's administrator was informed of the incidents and conducted interviews with residents and staff, leading to the immediate termination of S5CNA. The facility's policy on abuse recognition, reporting, and investigation was reviewed, revealing that residents should be protected from any physical and mental mistreatment, including verbal abuse, which was defined as the use of disparaging and derogatory terms to residents or their families.
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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 Orleans
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Jude's Health & Wellness Center | 1.5 mi | ★★★★★ | 16 | 2 |
| Chateau De Notre Dame Community Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| St Bernard Nursing & Rehab | 2.9 mi | ★★★★★ | 4 | 0 |
| Jefferson Healthcare Center | 3.5 mi | ★★★★★ | 6 | 0 |
| Ochsner Medical Center Skilled Nursing Facility | 3.8 mi | ★★★★★ | 0 | 0 |
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