F0677

E

Failure to Provide Timely ADL, Toileting, and Bed Mobility Assistance Due to Inadequate Staffing

Leesville, Louisiana Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary ADL services, including toileting, bed mobility, and personal hygiene, to multiple dependent residents in accordance with its own ADL policy and residents’ care plans. The facility’s policy stated that residents unable to carry out ADLs independently would receive appropriate support with hygiene, mobility, elimination, dining, and communication. Despite this, staff interviews and observations showed that residents who were dependent or required substantial/maximal assistance for ADLs were not consistently receiving timely assistance, particularly during the night shift when staffing on one hall was limited to a single CNA.

One CNA working the 7:00 p.m. to 7:00 a.m. shift on X hall reported being the only CNA assigned there, stating she was overworked, received no help, and could not complete all assigned duties, including getting approximately seven residents up in the morning. She stated that residents had to wait for the day-shift CNAs, who first had to serve breakfast before assisting them. She also reported that she had repeatedly informed her supervisor about her inability to accomplish her duties alone, but staffing had not changed. Another CNA on Y hall stated that most residents on Y hall were gotten up before the day shift, and that they did not have time to help on X hall because they had to get their own residents up.

Surveyor observations with staff confirmed multiple instances of unmet ADL needs. One resident, dependent on staff for toileting and requiring two-person assistance for bed mobility, was observed with both lower legs and feet dangling off the end of the bed after two CNAs had changed the resident’s brief and left him in that position, and the sole CNA on X hall stated she could not reposition him alone. Another resident, requiring substantial/maximal assistance for toileting and personal hygiene, was found with a strong urine odor and a wet brief because rounds had not yet been done. A totally dependent resident with neuromuscular bladder dysfunction, hemiplegia, and a stage 3 sacral pressure ulcer was observed with a strong BM odor, a soiled brief, and a Foley catheter bag containing 1300 cc of urine that had not been emptied. Additional residents who required assistance with toileting were observed with BM or urine odors and soiled or saturated briefs. LPNs on both halls confirmed that residents requiring ADL assistance should be assisted timely and should not remain in soiled briefs or with unmet ADL needs, and one LPN reported that when CNAs from Y hall left to assist on X hall, she was alone and unable to assist residents needing two-person help.