Consolata Rehab And Wellness Center On The Teche
Inspection history, citations, penalties and survey trends for this long-term care facility in New Iberia, Louisiana.
- Location
- 2319 East Main Street, New Iberia, Louisiana 70560
- CMS Provider Number
- 195618
- Inspections on file
- 21
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Consolata Rehab And Wellness Center On The Teche during CMS and state inspections, most recent first.
The facility failed to assess two residents for entrapment risks and did not obtain informed consent before using side rails. One resident, with a history of Hemiplegia and Bipolar Disorder, experienced entrapment resulting in a skin tear. Another resident with Vascular Dementia had side rails used without assessment or consent. The facility's policy requiring risk assessment and consent was not followed, leading to potential safety risks.
A resident with severe cognitive impairment was found with a serious leg injury of unknown origin, confirmed by X-ray as fractures. The facility's policy requires immediate reporting of such incidents to the state survey agency, but the Administrator failed to do so despite being informed by the DON. The oversight was acknowledged during interviews.
A facility failed to include the use of side rails in a resident's care plan, despite policy requirements. The resident, with conditions such as hemiplegia and bipolar disorder, had side rails in use without documentation in their Plan of Care. Observations and staff interviews confirmed the oversight.
A facility failed to maintain accurate medical records for a resident with chronic pain syndrome. The EMAR lacked documentation of Tylenol administration, despite the LPN's progress notes indicating the resident was in pain and assessed. The DON confirmed the documentation should have been completed.
A resident with specific dietary needs did not receive proper pleasure feedings due to inadequate training of CNAs. The resident's care plan required specific feeding techniques, including small bites, chin tucking, and remaining elevated post-meal. However, a CNA failed to follow these guidelines, and the DON did not ensure other staff were trained when the designated Restorative CNA was unavailable.
A resident was found with medication at their bedside without an order for self-administration or an assessment by the interdisciplinary team. The facility's policy requires such an assessment to ensure safety, but it was not conducted. Staff interviews confirmed the medication should not have been left with the resident, indicating a lapse in following the facility's procedures.
A facility failed to honor a resident's right to refuse care, specifically a bed bath, despite the resident's moderate cognitive impairment and multiple health conditions. The resident expressed a desire to refuse or delay the bath on days she did not feel well, but the CNA insisted on daily baths for all residents, disregarding the resident's choice and self-determination.
A resident's medical records were exposed when a medication cart was left unattended and unlocked outside the dining room area, allowing personal information to be visible to others. The facility's policy requires the use of a privacy screen when the computer is out of view, but an LPN confirmed she did not activate it, resulting in a breach of confidentiality.
A resident's care plan was not updated to reflect her wish to transfer to another facility, despite multiple requests and grievances. The resident's electronic health record and MDS assessment indicated a goal to remain in the facility, which was not revised by the interdisciplinary team. Interviews confirmed awareness of the resident's transfer request, but the care plan remained unchanged.
The facility failed to ensure medication carts were locked when unattended. Observations revealed that two medication carts were left unlocked and unattended in different areas of the facility. Staff confirmed that the carts should have been secured according to facility policy.
A resident with chronic health conditions and moderate cognitive impairment was unable to use the emergency call light in the bathroom due to a malfunction. The resident had to use a cellphone to contact a representative for help. The issue was confirmed by the surveyor, Administrator, and Maintenance Supervisor, but the DON was not informed, preventing interim accommodations.
A facility failed to notify a resident's physician when the resident's smoking privileges were revoked and nicotine mints were administered without a physician's order. The resident, who had intact cognition and was dependent on staff for care, was found to have nicotine mints in his room, provided by his grandmother. Interviews with staff revealed that the physician was not informed of these changes, leading to a deficiency in the resident's care plan.
A facility admitted a resident with a qualifying mental disorder without completing the required preadmission screening by the State Office of Behavioral Health. The resident's level 1 PASRR screening failed to include their diagnosis of Major Depressive Disorder, and no level 2 PASRR was completed. The Social Services Director confirmed the oversight during an interview.
The facility failed to develop comprehensive person-centered care plans within 7 days of completing the required MDS assessments for five residents with various diagnoses, as confirmed by the MDS Coordinator due to time constraints.
The facility failed to ensure proper medication storage and administration, including leaving medication at a resident's bedside, unattended medications on a cart, a controlled medication taped back into a blister pack, and improper storage of medications with food items in a refrigerator.
A resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These conditions were confirmed by the Housekeeping/Maintenance Supervisor as unacceptable.
The facility failed to develop comprehensive care plans for two residents, one with Alzheimer's disease who was improperly positioned in an oversized wheelchair, and another with Parkinson's Disease who was not care planned for limited range of motion. Staff confirmed the lack of appropriate documentation and care planning for both residents.
A resident with Alzheimer's Disease and high risk for pressure ulcers had a stage 3 pressure ulcer identified, but the facility failed to assess and document the ulcer until three days later. Interviews with staff confirmed the delay in assessment and treatment.
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident with severe cognitive impairment. The resident was observed without a chair alarm, despite the care plan indicating its use. The resident had a history of falls, including incidents where the bed alarm was malfunctioning or not in place, leading to injuries. Interviews with staff confirmed these findings.
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. One resident's oxygen tubing and humidifier were found on the floor, while another's nebulizer and oxygen equipment were left open to air and not labeled. Staff confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled.
The facility failed to ensure proper medication management for two residents. One resident did not receive their prescribed Plavix due to a failure in the re-ordering process, while another resident's Percocet count did not match the reconciliation sheet, and the medication was not signed as given.
The facility failed to maintain an effective infection control program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. Two LPNs were observed not following hand hygiene protocols, which was confirmed during interviews. This practice had the potential to affect the 70 residents in the facility.
The facility failed to post the most recent survey results in a place accessible to residents, family members, and legal representatives. The binder near the main entrance only contained older survey results, and the Administrator confirmed the absence of the latest complaint survey results.
Failure to Assess and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for the risk of entrapment from side rails, and informed consent was not obtained prior to their installation. Resident #2, who had a history of Hemiplegia and Hemiparesis, Bipolar Disorder, and Major Depressive Disorder, was found with his left leg entrapped between the side rail and the mattress, resulting in a skin tear. Despite this incident, there was no evidence of an assessment for the risk of entrapment, nor was there informed consent from the resident or his representative for the use of side rails. Additionally, ongoing monitoring and supervision of the side rails were not conducted. Resident #3, diagnosed with Vascular Dementia and Hemiplegia, was also not assessed for the risk of entrapment before the use of side rails. The resident's care plan included the use of side rails for bed mobility and repositioning, but there was no informed consent obtained from the resident or their responsible party. Observations confirmed that both upper half side rails were in the upward position, yet no assessment or consent documentation was found in the resident's medical record. Interviews with the Director of Nursing confirmed the lack of assessments and informed consents for both residents. The facility's policy on side rails, which requires an assessment of risks and benefits and obtaining consent, was not followed. This oversight led to the continued use of side rails without proper evaluation and documentation, posing a potential risk to the residents' safety.
Failure to Report Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident's injury of unknown origin to the state survey agency within the required timeframe. The facility's policy mandates that any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, must be reported immediately, or within two hours if the incident involves serious bodily injury. However, in this case, the facility did not adhere to this policy. On October 23, 2024, a resident with severe cognitive impairment was found with a swollen and misaligned right lower leg, indicating a serious injury. An X-ray confirmed comminuted displaced fractures of the tibia and fibula. The Director of Nursing (DON) was informed of the injury on the same day and notified the Administrator. Despite this, the Administrator did not report the incident to the state survey agency as required. The failure to report was confirmed during interviews with both the DON and the Administrator. The Administrator acknowledged the oversight and confirmed that the resident was sent to the hospital for treatment of the injury, which was of unknown origin.
Failure to Document Side Rail Use in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident by not including the use of side rails in the Plan of Care. The facility's policy on physical restraints and side rails, last reviewed in January 2024, mandates that the use of side rails as assistive devices must be addressed in the resident's care plan. However, a review of the resident's medical record revealed that there was no documentation regarding the use of side rails, despite the resident having been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, bipolar disorder, and major depressive disorder. An observation on November 21, 2024, noted that the resident's bed had the left upper side rail in the upward position and the right upper side rail in the downward position, with the bed's right side against the wall. A CNA confirmed that the side rails had been used in this manner since she began working at the facility a month prior. The Director of Nursing also confirmed that the use of side rails was not documented in the resident's Plan of Care, indicating a failure to adhere to the facility's policy and ensure the resident's care plan was comprehensive and person-centered.
Incomplete Documentation in EMAR for Pain Management
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for one of the sampled residents. Specifically, the Electronic Medication Administration Record (EMAR) for a resident was incomplete and inaccurately documented. The resident, who was admitted with diagnoses including Muscle Wasting and Atrophy, Osteoporosis, Osteoarthritis, and Chronic Pain Syndrome, had a physician's order for Tylenol to be administered as needed for pain. On a specific date, a Licensed Practical Nurse (LPN) was notified by a Certified Nursing Assistant (CNA) to assess the resident, who was in pain and unable to move or flex her right foot. Despite the LPN's progress notes indicating that the resident was assessed and in pain, there was no documentation in the EMAR that Tylenol was administered to the resident at that time. During an interview, the Director of Nursing (DON) confirmed that nurses are required to document all administered medications in the EMAR and acknowledged the absence of documentation for the administration of Tylenol, which should have been recorded.
Inadequate Training for Pleasure Feedings
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in administering pleasure feedings to a resident with specific dietary needs. The resident, who had a history of malnutrition, vitamin D deficiency, type 2 diabetes, and chronic kidney disease, required PEG tube feedings along with pleasure feedings. The resident's care plan, as outlined in a Speech Therapy Discharge Summary and Restorative Nursing Program Recommendations, specified that the resident should receive small bites and sips, be cued to tuck their chin and double swallow, and remain in an elevated position for at least thirty minutes after eating. However, during an observation, a CNA provided the resident with puree eggs and honey-thickened liquids through a straw without following these guidelines, failing to cue the resident appropriately and allowing the resident to lower their bed immediately after eating. Interviews revealed that the CNA was not aware of the specific feeding instructions and had not been trained on the resident's pleasure feeding protocol. The Director of Nursing (DON) had received the resident's restorative plan but did not ensure that other staff members were trained to administer the feedings when the designated Restorative CNA was unavailable. The facility's administrator acknowledged that the restorative program was specific and did not consider it feasible to train other CNAs on these tasks. This lack of training and communication led to the deficiency in care for the resident.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The interdisciplinary team did not assess the resident's mental and physical abilities to determine if self-administration was clinically appropriate. The resident, who had a BIMS score indicating intact cognition, was observed with two medicine cups containing a liquid medication at their bedside. The medication was identified as magic mouthwash, which was prescribed for the resident's sore mouth. However, there was no physician's order allowing the resident to self-administer this medication, nor was there an assessment or care plan in place to support self-administration. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the medication should not have been left at the resident's bedside. The LPN denied leaving the medication and was unsure who did, while the Director of Nursing confirmed the absence of an order for self-administration. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, which requires a formal assessment and documented approval by the interdisciplinary team.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not accommodating a resident's choice to refuse care. The resident, who has moderate cognitive impairment and multiple health conditions including COPD, coronary artery disease, and depression, expressed a desire to refuse a bed bath on certain days when she did not feel well. Despite this, the facility's staff, specifically a CNA, did not honor the resident's request to refuse or delay the bath, insisting that all residents receive a daily bath regardless of their wishes. Interviews with the resident revealed that she was not allowed to refuse a bed bath, and her request to have a bath at a later time was not honored. The CNA confirmed that residents who do not go to the whirlpool receive a bed bath daily and did not acknowledge the resident's right to refuse care. The CNA stated that everyone wants to feel clean and did not provide an option for the resident to refuse a bath, even for hospice residents, indicating a lack of support for resident choice and self-determination.
Breach of Resident Confidentiality Due to Unattended Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, as observed during a survey. The incident involved a medication cart, identified as Medication Cart B, which was left unattended and unlocked outside the dining room area. This allowed the personal information of one resident to be visible to visitors and other residents. The facility's policy on the security of medication carts requires that a computer privacy screen be initiated when the computer is out of the nurse's view. However, during an interview, an LPN confirmed that she did not activate the privacy screen before leaving the cart unattended, leading to the breach of confidentiality.
Failure to Update Resident's Care Plan for Transfer Request
Penalty
Summary
The facility failed to ensure that a resident's person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the sampled residents, who had expressed a desire to transfer to another facility. Despite the resident's grievance and multiple requests for transfer, the care plan continued to reflect the resident's goal to remain in the facility. The resident's electronic health record indicated that she was admitted with diagnoses including urinary tract infection, chronic kidney disease, schizophrenia, and bipolar disorder. Her 5-day Minimum Data Set (MDS) assessment also noted her goal to stay in the facility, which was not updated to reflect her current wishes. Interviews with the Social Service Director and the MDS coordinator revealed that the resident had repeatedly requested a transfer, and efforts were made to facilitate this, including communication with other facilities. However, these requests were denied, and the care plan was not updated to reflect the resident's current goal of transferring. The MDS coordinator acknowledged awareness of the resident's wish to transfer and confirmed that the care plan should have been revised to reflect this change.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. On Hall A, Medication Cart A was found unlocked and unattended while an LPN was engaged in a personal phone call at the nurse's station. The LPN confirmed that the cart should have been locked before leaving it unattended. Similarly, on Hall B, Medication Cart B was observed unlocked and unattended near the nurse's station, with a visitor present in the hallway. The Assistant Director of Nursing confirmed that the cart should have been secured. Further observations revealed that Medication Cart B was again found unlocked and unattended outside the dining room area. An LPN confirmed that the cart should have been locked before leaving it unattended. These observations indicate a failure to adhere to the facility's policy requiring medication carts to be locked when not in use, posing a potential risk to the security of medications.
Non-Functional Call System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that the resident call system was functioning properly for one of the sampled residents. The deficiency was identified when a resident, who had been admitted with multiple chronic conditions including Chronic Systolic Heart Failure and Type 2 Diabetes Mellitus, attempted to use the emergency call light in the bathroom but found it non-functional. The resident, whose cognitive status was moderately impaired, had an accident and was unable to summon help using the call light. Instead, he had to call his representative via cellphone, who then contacted the facility to get assistance for him. Upon investigation, the surveyor confirmed that the call light in the resident's bathroom did not work, as it failed to activate the indicator outside the room or alert the front desk. The facility's Administrator and Maintenance Supervisor both verified the malfunction during their checks. The Director of Nursing was not informed about the issue, which prevented any interim measures from being implemented to accommodate the resident's needs until the call light was repaired.
Failure to Notify Physician of Changes in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a resident's physician was consulted when there was a change in the plan of care. Specifically, the facility did not notify the physician when a resident's smoking privileges were revoked due to noncompliance with facility smoking policies. Additionally, the staff administered nicotine mints to the resident without a physician's order. This oversight was discovered during a review of the resident's care plan and electronic medical records, which showed no documentation of physician notification regarding these changes. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, Administrator, and Assistant Director of Nursing, revealed that the resident's physician was not informed of the changes in the resident's care plan. The Social Service Director noted that the resident's grandmother had purchased nicotine mints for the resident, which were being given to him by the CNAs. The Nurse Practitioner confirmed that she was not aware of the resident's loss of smoking privileges or the need for an order for nicotine mints. The Administrator and Assistant Director of Nursing acknowledged that they had not followed up with the physician regarding these changes, leading to the deficiency.
Failure to Complete PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a qualifying mental disorder was not admitted before a preadmission screening by the State Office of Behavioral Health (OBH) was completed. The resident, who was admitted with diagnoses including Anxiety Disorder, Unspecified Mood Disorder, and Major Depressive Disorder, had a level 1 PASRR screening dated 08/17/2023. However, the screening incorrectly indicated no suspected or diagnosed mental illness, and there was no level 2 PASRR completed. During an interview, the Social Services Director confirmed that the resident was admitted with a diagnosis of Major Depressive Disorder from another facility and acknowledged that this diagnosis should have been included in the level 1 screening.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS for five residents. The residents involved had various diagnoses, including Hepatitis A, Type 2 Diabetes Mellitus, Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Heart Failure, Schizoaffective Disorder, Acute Kidney Failure, Anxiety Disorder, Depression, Chronic Pain Syndrome, Hypertension, Spinal Stenosis, Tachycardia, Dementia, and Congestive Heart Failure. Despite the completion of their Annual MDS assessments, their Electronic Health Records (EHR) did not contain the required comprehensive care plans. An interview with the Minimum Data Set Coordinator (MDSC) revealed that the comprehensive care plans for these residents were not developed due to time constraints and being months behind schedule. The MDSC confirmed the deficiency, acknowledging that the care plans were supposed to be completed but were not. This lapse affected the quality of care planning for the residents involved.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflected current standards of practice. Specifically, medication was left at a resident's bedside without proper authorization or assessment for self-administration. Additionally, medications were left unattended on top of a medication cart, and a controlled medication was found taped back into a blister pack. Furthermore, medications were stored together with food items in a refrigerator, and some medications were not labeled with the resident's name. Resident #31 had Flonase allergy spray left on her bedside table without documented evidence of a request or assessment for self-administration. An LPN confirmed the medication should have been securely stored. Another LPN left multiple medications unattended on top of a medication cart while retrieving a narcotics binder. A random narcotic check revealed a Percocet tablet taped back into a punctured blister pack. Additionally, a tour of a resident's supplement refrigerator found medications stored with food items, and some medications were not labeled with the resident's name.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident diagnosed with Acute Embolism and Thrombosis of Unspecified Deep Veins of the Left Lower Extremity and Moderate Protein Calorie Malnutrition. On two separate observations, the resident's bathroom was found to have a copper-colored stain on the sink and toilet, a large paint blister on the wall, and a moderate build-up of dust on the ceiling vent. These findings were confirmed by the Housekeeping/Maintenance Supervisor, who acknowledged that the conditions were unacceptable.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive plan of care for two residents, leading to deficiencies in addressing their specific needs. Resident #13, diagnosed with Alzheimer's disease, was observed multiple times slouched in an oversized high back wheelchair, which was not appropriate for her size. Despite the family's insistence on using this wheelchair, the care plan did not document this insistence or address the issue. Interviews with staff, including the Director of Nursing and the Minimum Data Set Coordinator, confirmed the lack of documentation and appropriate care planning for the resident's positioning needs. Resident #17, diagnosed with Parkinson's Disease, Muscle Weakness, Repeated Falls, and Contracture of the Right Hand, was not care planned for her limited range of motion. Observations revealed that the resident's right hand was clenched in a fist without a hand roll, and she was unable to open her hand fully. Interviews with staff confirmed that the resident did not have a hand roll and that her limited range of motion was not addressed in her care plan, despite the problem existing at the time the comprehensive care plan was completed.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received the necessary treatment and services to promote healing. Resident #13, who was diagnosed with Alzheimer's Disease and assessed as high risk for pressure ulcer development, had a pressure ulcer identified on 01/22/2024. However, there was no evidence that an assessment of the pressure ulcer was done on the same day. The first documented assessment of the pressure ulcer was on 01/25/2024, three days after it was initially identified, and it was noted as a stage 3 pressure ulcer with specific measurements and characteristics. Interviews with the Assistant Director of Nursing Infection Preventionist (S3ADONIP) and the Director of Nursing (S2DON) confirmed the lack of timely assessment. S3ADONIP acknowledged identifying the pressure ulcer on 01/22/2024 but could not provide evidence of an assessment on that date. S2DON also confirmed that an assessment should have been done immediately when the pressure ulcer was identified, rather than three days later. This delay in assessment and treatment constitutes a failure to provide necessary care for the resident's pressure ulcer.
Failure to Ensure Adequate Supervision and Assistance to Prevent Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for a resident diagnosed with unspecified dementia with other behavioral disturbances. The resident, who had a severely impaired cognition with a BIMS score of 3, was observed without a chair alarm attached to their wheelchair, despite the care plan indicating the use of bed and chair alarms as fall prevention measures. Interviews with CNAs confirmed the absence of the chair alarm during the observation. Additionally, the resident had a history of falls, including incidents where the bed alarm was either malfunctioning or not in place, leading to injuries such as a skin tear on the right forearm. The resident's electronic clinical record and progress notes revealed multiple falls, including one where the bed alarm was found to be malfunctioning and another where there was no documentation of the bed alarm being in place. Interviews with the Director of Nursing and the Assistant Director of Nursing Infection Preventionist confirmed these findings. The facility's failure to ensure the proper functioning and use of bed and chair alarms contributed to the resident's falls and subsequent injuries.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to properly store and label respiratory equipment for two residents, leading to deficiencies in respiratory care. For Resident #9, who has severe cognitive impairment and a history of acute and chronic respiratory failure, the oxygen tubing and humidifier were found on the floor, open to air, and not labeled. This was confirmed by an LPN who acknowledged that the equipment should have been stored in a bag and labeled with the date. The resident's care plan indicated a need for oxygen therapy as needed, but the facility did not adhere to its own policy or state and federal guidelines for equipment storage and labeling. Similarly, Resident #16, who has moderate cognitive impairment and chronic obstructive pulmonary disease, had a nebulizer with mouthpiece and tubing stored on the dresser, open to air, and without a date. The resident's oxygen tubing and humidifier were also in use but not labeled. A CNA confirmed these observations and acknowledged that the equipment should have been stored in a bag and labeled. The Assistant Director of Nursing and Infection Preventionist also confirmed that the facility's procedures were not followed in both cases, leading to the deficiencies observed by the surveyors.
Failure to Ensure Proper Medication Management
Penalty
Summary
The facility failed to ensure that medications and pharmaceutical services were provided to meet the needs of two residents. For Resident #25, the facility did not re-order and administer Plavix, a blood thinner, as required. The resident's clinical record showed an order for Plavix 75 mg to be taken every other day. On two separate occasions, it was observed that the medication was not available in the medication cart, and the nurse had to call the pharmacy to order it. The Director of Nursing and Assistant Director of Nursing confirmed that the procedure for re-ordering medications was not followed, as they were not notified about the missing medication. For Resident #31, the facility failed to maintain a system to account for the usage and reconciliation of controlled medications. During a random narcotic check, it was found that the number of Percocet pills in the blister pack did not match the count on the narcotic reconciliation sheet. Additionally, the medication was not signed as given on the electronic medication administration record. Both the LPN and RN confirmed the discrepancy and acknowledged that the medication should have been reconciled and signed off at the time it was administered.
Failure to Perform Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not performing hand hygiene before preparing medications and after removing gloves following patient contact. On 04/02/2024, an LPN was observed drawing up insulin, administering it to a resident, and then removing her gloves without performing hand hygiene. She then proceeded to pour medications without sanitizing her hands. During an interview, the LPN confirmed that she did not perform hand hygiene and acknowledged that she should have done so after contact with the resident and removing her gloves. Another LPN was observed on the same day preparing medications without performing hand hygiene after handling a Hoyer lift. She confirmed during an interview that she did not perform hand hygiene before starting to prepare medications and acknowledged that she should have. The Assistant Director of Nursing, who is also the Infection Preventionist, stated that hand hygiene should be performed before and after patient contact and before donning and after removing gloves. This deficient practice had the potential to affect the 70 residents residing in the facility.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to ensure the most recent survey results were posted in a place readily accessible to residents, family members, and legal representatives. During an observation on 04/02/2024, it was noted that the survey results from a complaint survey conducted on 04/11/2023 were not included in the binder labeled LDH DHH Licensing survey, which was located near the facility's main entrance. The binder only contained results from annual surveys conducted on 03/22/2023 and 02/23/2022. The Administrator confirmed the absence of the most recent survey results in the designated area for public review.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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