Gonzales Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gonzales, Louisiana.
- Location
- 905 West Cornerview Road, Gonzales, Louisiana 70737
- CMS Provider Number
- 195327
- Inspections on file
- 29
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gonzales Healthcare Center during CMS and state inspections, most recent first.
A resident with cognitive intactness and incontinence issues was neglected due to a miscommunication between CNAs about their assignments, resulting in the resident being left wet and dirty for an extended period. The facility's investigation confirmed the neglect, highlighting a failure in staff communication and assignment management.
A facility failed to implement its abuse policy by not ensuring staff reported an allegation of verbal abuse. A resident with intact cognition reported that a CNA was disrespectful and told her to shut up. This was reported to the social worker, but the SSA did not report the allegation to anyone, including the Administrator, who confirmed it should have been reported immediately.
A resident with cerebral palsy, dependent on staff for eating, alleged verbal abuse by a CNA. The facility's administrator was informed of the allegation but failed to report it to the State Agency within the required timeframe, delaying the report by three days.
The QAPI committee failed to provide evidence of ongoing monitoring and evaluation of corrective actions after numerous abuse and neglect allegations. Despite conducting in-services on abuse policies in January, there was no documentation of similar training in February or evaluation of the training's effectiveness. The administrator admitted to not monitoring the effectiveness of the training, relying instead on the number of incidents reported to the state agency.
A resident with intact cognition experienced verbal abuse from a former Activities Director during a discussion about attending a health fair. The staff member raised their voice and pointed a finger at the resident, telling her to stop crying. The incident was witnessed by the Regional Vice President, who confirmed the inappropriate behavior. The facility Administrator substantiated the verbal abuse.
The facility did not ensure the activities program was led by a qualified professional, as the former Activities Director lacked documented qualifications required by the job description. The administrator confirmed the absence of necessary documentation for the role.
The facility failed to report the results of neglect investigations involving two residents to the State Survey Agency within the required time frame. Initial reports were made, but final reports were delayed due to administrative access issues and the absence of the responsible administrator, leading to non-compliance with reporting timelines.
The facility failed to thoroughly investigate neglect allegations involving two residents. For one resident, witness statements from an LPN and CNA were not validated due to missing signatures. For another resident, there was no documented evidence of an interview being conducted regarding the neglect allegation. The administrators acknowledged these deficiencies in the investigation process.
The QAPI committee failed to ensure ongoing monitoring and evaluation of corrective actions for incontinence care. Despite a plan for ADL documentation, a resident lacked documented assistance with toilet use on several nights. Interviews confirmed the absence of monitoring tools and non-compliance with the QAA plan by CNAs, with no evidence of staff training or disciplinary actions.
The facility failed to secure two residents properly in its transportation vehicles, leading to an Immediate Jeopardy situation. One resident's wheelchair tipped over during transport, causing a head injury, while another was transported without using the required shoulder strap. These incidents occurred due to staff not adhering to the facility's safety protocols.
The facility failed to ensure the safe transportation of residents, resulting in a resident's injury due to improper securing in a transport bus. Incomplete transportation logs and missing safety inspections further highlighted the deficiency in oversight and adherence to safety protocols.
A transportation driver verbally abused a resident by refusing to assist with paperwork and yelling at the resident during a physician's appointment. The resident, who was cognitively intact and had multiple medical conditions, reported the incident, which was corroborated by a bystander and staff from the physician's office. The facility's investigation confirmed the verbal abuse.
A facility failed to report the results of an investigation into an allegation of neglect involving a resident to the state agency within the required 5 working days. The report was due but was submitted a day late, as confirmed by a Corporate Clinical Specialist.
A facility failed to investigate an alleged neglect incident involving a resident who required substantial assistance for toileting. The resident reported delays in receiving care, with a call light alarm log showing a 96-minute wait. The facility's investigation lacked specific details and did not include a statement from the CNA responsible during the incident.
A resident with moderately impaired cognition and incontinence was left unchanged and unattended by a CNA for several hours, resulting in the resident being found saturated with urine. The incident was confirmed by the facility's administrator.
The facility failed to protect residents from abuse and neglect. A resident was physically abused by another resident, two residents were involved in a physical altercation, a resident was verbally abused and neglected by a CNA, and two residents were neglected by another CNA. These incidents highlight significant lapses in the facility's duty to ensure resident safety and well-being.
A resident with dysphagia requiring tube feeding was not administered the correct water flush as ordered by the physician. The tube feeding pump was set to deliver 125mL every 4 hours instead of the prescribed 150mL every 6 hours, a discrepancy confirmed by both the LPN and DON.
The facility failed to ensure a resident's PRN order for Lorazepam had a specified duration documented by the physician. The resident, admitted with mood and bipolar disorders, had Lorazepam administered 33 times without a defined duration after the initial 14 days, as confirmed by staff interviews and record reviews.
A resident with hypertension did not receive their prescribed Clonidine HCL 0.1 mg patch as ordered. The LPN documented the administration but failed to apply the patch, leaving an old patch in place and not notifying the physician until days later.
The facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services. The resident had diagnoses including stroke, seizure disorder, and malnutrition. The facility did not have any documentation of hospice services since early April 2024, and there was no designated staff member responsible for ensuring the hospice documentation was up-to-date.
A CNA failed to perform proper hand hygiene during incontinence and catheter care for a resident with a urinary catheter and recent urinary tract infection. The CNA did not wash hands before putting on gloves, after removing soiled gloves, or after completing care, contrary to the facility's hand hygiene policy.
A facility failed to report an injury of unknown origin for a resident with Alzheimer's disease. The resident was found with a swollen lip and red cheek, but the DON did not document the assessment or report the incident to the Administrator. The resident could not explain the injury due to severe cognitive impairment.
A resident with Alzheimer's disease and severely impaired cognition was found with a swollen lip and red cheek. Despite being assessed by an LPN and the DON, no documentation or investigation into the cause of the injuries was conducted, and the Administrator was unaware of the incident.
Neglect Due to Staff Miscommunication
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the failure of nursing staff to provide necessary peri-care. The incident involved a resident who was admitted with multiple diagnoses, including dysphagia following cerebral infarction and neuromuscular dysfunction of the bladder. The resident was cognitively intact, as indicated by a BIMS score of 15, and was always incontinent of bowel and bladder, requiring staff assistance for toileting hygiene needs. The resident's care plan specified that staff should perform incontinent care during daily care and as needed, change clothing after incontinence episodes, and provide briefs or incontinent pads as necessary. The neglect occurred due to a miscommunication between two CNAs regarding their assignments, resulting in the resident being left wet and dirty for an extended period. The oncoming CNAs confirmed the resident's allegations of neglect, finding the resident in an oversaturated and dirty brief. The facility's investigation substantiated the resident's claim of neglect, with the DON confirming that the miscommunication between the CNAs led to the neglect. The incident highlights a failure in staff communication and assignment management, which directly resulted in the resident not receiving the necessary care to prevent neglect.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not ensuring that staff reported an allegation of verbal abuse. The facility's Abuse Prohibition policy mandates that any employee aware of an abuse allegation must report it immediately to the abuse coordinator. Resident #1, who had an intact cognition as indicated by a Brief Interview of Mental Status score of 15, reported that a Certified Nursing Assistant (CNA) was disrespectful and told her to shut up. This incident was reported to the social worker on the morning of 03/03/2025. However, the Social Service Assistant (SSA) did not report this allegation to anyone, including the Administrator, who confirmed that the allegation should have been reported immediately.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse and/or neglect to the State Agency in a timely manner, as required by their Abuse Prohibition policy. The policy mandates that all allegations of abuse be reported immediately or within two hours. However, the facility did not report an allegation involving a resident until three days after it was made. The resident, who has cerebral palsy and is dependent on staff for eating, alleged that a CNA told her to learn how to feed herself, which could be considered verbal or mental abuse. The incident was documented during Life Satisfaction Rounds by a Social Service Assistant, who reported the allegation to the facility's administrator on the same day. Despite being aware of the allegation, the administrator did not report it to the State Agency until three days later. This delay in reporting constitutes a failure to adhere to the facility's policy and regulatory requirements for timely reporting of suspected abuse or neglect.
Failure to Monitor and Evaluate Abuse and Neglect Training
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to demonstrate that ongoing monitoring and evaluations were implemented to ensure corrective actions were in place following numerous allegations of abuse and neglect identified in 2024. The facility's Quality Assessment and Assurance (QAA) policy indicated that the committee would develop and implement plans to correct identified deficiencies. However, the review of the facility's Immediate Plan of Improvement for Abuse and Neglect revealed that while the facility identified concerns regarding abuse and neglect allegations, there was insufficient evidence of effective implementation and monitoring of corrective actions. The facility conducted in-services on abuse policies and procedures in January 2025, but there was no documented evidence of similar training in February 2025. Additionally, there was no evidence that the facility evaluated the effectiveness of the January 2025 training or monitored reported incidents. During an interview, the administrator admitted to not having documentation of monitoring the effectiveness of the in-services and stated that the facility did not need to monitor the effectiveness of the training, as it could be determined by the number of incidents reported to the state agency. This approach suggested a reactive rather than proactive stance on addressing abuse and neglect, as the administrator indicated that the facility's plan was to wait for incidents to occur rather than actively monitor and evaluate staff training effectiveness.
Verbal Abuse Incident Involving Staff and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically the former Activities Director. The incident involved a resident with intact cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The resident required staff assistance for emotional, intellectual, physical, and social needs. The verbal abuse occurred when the resident inquired about attending a health fair, and the staff member responded in a raised voice, pointing a finger at the resident and telling her to stop crying. This interaction was witnessed by the Regional Vice President, who confirmed the inappropriate behavior. Further interviews revealed that the incident began in the dining room when the resident asked about the health fair and was told that transportation was unavailable due to a broken van. The situation escalated when the staff member later entered the resident's room, and a heated exchange ensued, with both parties yelling. The Regional Vice President and the facility Administrator substantiated the verbal abuse, confirming that the staff member's conduct was inappropriate and constituted verbal abuse.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by their job description for the Activities Director position. The job description specified that the Activities Director must possess at least two years of college education and meet certain experience or certification criteria, such as being a qualified therapeutic recreation specialist, an activities professional licensed by the state, or having relevant experience in a health care setting. However, a review of the personnel record for the former Activities Director (S4FAD) revealed no documented evidence of meeting these qualifications. During an interview, the facility's administrator confirmed the absence of documentation proving S4FAD's qualifications for the role.
Delayed Reporting of Neglect Investigations
Penalty
Summary
The facility failed to report the results of investigations into allegations of neglect involving two residents to the State Survey Agency within the required time frame. For Resident #1, an allegation of neglect was initially reported on 09/03/2024, with the final investigation report due by 09/10/2024. An extension was granted until 09/12/2024, but the report was not submitted until 09/16/2024. The delay occurred because the S1Administrator, who was responsible for submitting the report, did not return to work until 09/16/2024, and the S2Interim Administrator did not have access to the necessary system to submit the report. Similarly, for Resident #3, an allegation of neglect was reported on 09/03/2024, with the final report also due by 09/10/2024. An extension was granted until 09/12/2024, but the report was not submitted until 09/16/2024. The S2Interim Administrator was unable to submit the report due to lack of access to the State Incident Management System, and the S1Administrator submitted it upon returning to work. These delays in reporting the investigation results constitute a failure to comply with the required reporting timelines.
Inadequate Investigation of Neglect Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of neglect involving two residents. For Resident #2, the investigation was incomplete as the witness statements from the LPN and CNA involved were not properly validated. The statements were photocopies without signatures, which compromised their validity. The administrator acknowledged that a photocopy of a text message should not have been used as a witness statement and that the statements should have been signed to ensure their authenticity. For Resident #3, the facility did not document any evidence of an interview being conducted with the resident regarding the neglect allegation. The interim administrator admitted to not obtaining a witness statement from Resident #3 as part of the investigation. This lack of documentation and failure to interview the resident indicates a deficiency in the facility's investigation process for allegations of neglect.
Failure in Monitoring and Documentation of Incontinence Care
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to demonstrate that ongoing monitoring and evaluations were effectively implemented to ensure corrective actions were in place for residents not receiving incontinence care as needed. The facility's Quality Assessment and Assurance (QAA) committee was expected to regularly review and analyze data to make improvements and develop plans of action to correct identified quality deficiencies. However, despite a plan of action being implemented for timely documentation of activities of daily living (ADL) on April 18, 2024, following a prior complaint survey, there was no documented evidence of monitoring or evaluation of these corrective actions. Specifically, the Documentation Survey report for September 2024 revealed that a resident did not have documented evidence of assistance with toilet use and/or toilet transfer during the night shift on multiple dates. Interviews with the Corporate Clinical Specialist and the Director of Nursing (DON) confirmed the absence of documentation and monitoring tools for ADL documentation as per the facility's QAA plan. The DON also indicated that the QAA plan was not being followed by Certified Nursing Assistants (CNAs) and could not provide evidence of staff in-service training or disciplinary actions for non-compliance with the QAA plan.
Failure to Secure Residents in Transportation Vehicles
Penalty
Summary
The facility failed to properly secure residents in its transportation vehicles, leading to an Immediate Jeopardy situation. Resident #5 was not secured in a forward-facing direction in the facility's transportation bus, resulting in the resident's wheelchair tipping over backwards during transport. This incident caused Resident #5 to strike the back of her head, leading to an abrasion and the need for pain medication at a local emergency department. The facility's policy required that residents in wheelchairs be forward-facing, but this was not adhered to by S6Driver, who admitted to not securing Resident #5 properly. Similarly, Random Resident #6 was not secured with the shoulder strap in the facility's transport van by S4ActivitiesDirector. Despite the facility's policy mandating the use of shoulder straps, S4AD did not use them, believing they were unnecessary. This oversight was observed as Random Resident #6 was transported without the proper restraints, which was against the facility's guidelines. Both incidents highlight a failure to follow established safety protocols, putting residents at risk during transportation.
Deficiency in Resident Transportation Safety
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a deficiency in the safe transportation of residents. The deficiency was identified when a driver failed to properly secure a resident in a forward-facing direction in the facility's transportation bus, resulting in the resident's wheelchair tipping over and causing the resident to strike the back of her head. This incident led to the resident being transported to the hospital for an abrasion and pain management. Additionally, another resident was observed being improperly restrained in a transport van, highlighting a systemic issue with the facility's transportation safety protocols. The facility's transportation logs were found to be incomplete, with missing entries for mileage and times, and no record of the incident involving the first resident. Furthermore, the facility failed to conduct weekly safety inspections of its transportation vehicles, as evidenced by blank inspection forms for several weeks. Interviews with the facility's administrator and maintenance director confirmed the lack of documented evidence for these inspections and audits, indicating a failure in oversight and adherence to established safety regulations.
Verbal Abuse by Transportation Driver
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff, as evidenced by an incident involving a transportation driver. The incident occurred when the transportation driver, identified as S4TD, refused to assist a resident with filling out paperwork at a physician's office and verbally abused the resident by yelling that there was nothing wrong with his hands, only his legs. This behavior was reported by an anonymous bystander and corroborated by staff from the physician's office. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14, and had been admitted with diagnoses including right ankle effusion, sepsis, generalized weakness, and an injury to the left eye. The incident was documented in the facility's records, and the facility's Abuse Prohibition Policy defined verbal abuse as the use of disparaging or derogatory language. The facility's investigation substantiated the occurrence of verbal abuse, leading to the suspension and subsequent termination of the transportation driver.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of an investigation to the required state agency within the mandated timeframe of 5 working days following a reportable incident. This deficiency involved a resident who was the subject of an allegation of neglect, which was initially reported on 05/30/2024. According to the facility's documentation, the investigation report for this incident was due to be submitted to the state survey agency by 06/06/2024. However, during an interview on 06/13/2024, the Corporate Clinical Specialist acknowledged that the results of the investigation were not submitted until 06/07/2024, missing the deadline by one day.
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of neglect involving a resident with intact cognition who required substantial assistance for toileting. The resident reported issues with receiving timely care from the night staff, specifically on two occasions where they had to yell for help after pressing the call light. The facility's incident report noted an extended wait time for assistance but lacked specific details such as the date or time of the incident. Additionally, the investigation did not include a statement from the CNA responsible for the resident during the time in question. The resident's call light alarm log showed a significant delay of 96 minutes on one occasion, yet the facility did not document any investigation into the cause of this delay or identify the staff member involved. Interviews with the facility's administration confirmed that the investigation report did not include necessary information, such as the nurse's notes or a statement from the CNA. This lack of thorough investigation and documentation constitutes a deficiency in addressing the alleged neglect.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a dependent resident, identified as Resident #5, who had moderately impaired cognition and was incontinent of bowel and bladder. According to the Minimum Data Set (MDS) assessment, Resident #5 was dependent on staff for toileting. An incident report was initiated following an allegation of neglect, where it was reported that Resident #5 was not changed by the day shift Certified Nursing Assistant (CNA) on a specific date. The accused CNA, identified as S7CNA, confirmed that she did not return to Resident #5's room to provide care after lunch, leaving the resident unattended from approximately 11:30 a.m. until the end of her shift at 7:00 p.m. The evening shift CNA, identified as S8CNA, found Resident #5 saturated with urine at the start of her shift, with the urine having soaked through the adult brief, incontinence pad, and onto the sheets. The facility's administrator, S1Administrator, confirmed the details of the incident, acknowledging that Resident #5 should not have been left unchanged and unattended for such an extended period. This failure to provide necessary incontinence care resulted in the resident being left in a saturated state for several hours.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse and neglect. Resident #75 was physically abused by Resident #239 when the latter hit Resident #75's hand after their wheelchairs made contact in the dining room. This incident was confirmed by video surveillance footage reviewed by the administrator. Additionally, Resident #43 and Resident #47 were involved in a physical altercation in the dining room, which was witnessed by staff members. Both residents had severe cognitive impairments and a history of aggressive behavior, but the cause of the fight could not be determined, and it was confirmed that the altercation was intentional and not accidental. Resident #37, who was cognitively intact, reported being verbally abused and neglected by a CNA. The resident stated that the CNA canceled her call light and did not provide assistance until the next shift, resulting in a 95-minute wait to be changed. The administrator substantiated the resident's claims and terminated the CNA involved. Furthermore, Residents #20 and #23 were found heavily saturated with urine and feces, indicating neglect by another CNA who was assigned to them for the shift. Both residents required total dependence on staff for toileting and were not assisted throughout the shift, as confirmed by staff statements and the administrator's investigation. The facility's failure to protect residents from abuse and neglect is evident in these incidents. The abuse prohibition policy was not effectively implemented, leading to physical abuse between residents, verbal abuse, and neglect by staff members. The incidents highlight significant lapses in the facility's duty to ensure the safety and well-being of its residents, particularly those with cognitive impairments and high dependency on staff for daily care.
Failure to Administer Tube Feeding Water Flush as Ordered
Penalty
Summary
The facility failed to administer a resident's tube feeding water flush as ordered. Resident #50, who had dysphagia and required nutrition and hydration through a feeding tube, had a physician's order for a water flush of 150 milliliters (mL) every 6 hours. However, observations on multiple occasions revealed that the resident's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours instead. This discrepancy was confirmed by both the Licensed Practical Nurse (LPN) and the Director of Nursing (DON), indicating that the resident was not receiving the correct amount of water flush as prescribed. The deficiency was identified through record reviews, observations, and interviews. The Minimum Data Set and the resident's care plan both indicated the correct order for the water flush. Despite this, the tube feeding pump was consistently set incorrectly over several days. The LPN and DON both acknowledged the error, confirming that the resident's tube feeding water flush was not being administered according to the physician's orders.
Failure to Document Duration for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident did not have an order for the administration of a psychotropic medication on an as-needed (PRN) basis without a physician's documentation of the specified duration of the order. Resident #46 was admitted with diagnoses of unspecified mood disorder and bipolar disorder. The resident had a physician's order for Lorazepam 0.5 mg every 12 hours as needed for anxiety related to bipolar disorder, starting on 11/20/2023. The consultant pharmacist requested the physician to address the PRN order, noting that such orders are limited to 14 days and require reevaluation before extension. However, the physician documented to continue the use of the medication without specifying the duration, and the order was signed on 12/05/2023. Resident #46's Individual Resident Narcotic Record showed that Lorazepam 0.5 mg was administered 33 times since admission. During interviews, both the Licensed Practical Nurse and the Director of Nursing confirmed the existence of the PRN order and the lack of documentation specifying the duration of the PRN Lorazepam order after 14 days. There was no documented evidence presented by the facility to show that the physician had defined the duration of the continued use of Lorazepam on a PRN basis after the initial 14 days.
Failure to Administer Hypertension Medication as Ordered
Penalty
Summary
The facility failed to administer a medication for hypertension as ordered by the physician for one resident. Resident #14, who was admitted with a diagnosis of hypertension, had a physician's order for Clonidine HCL 0.1 mg patch to be applied transdermally every Friday. However, the patch dated 05/03/2024 was still observed on Resident #14's right upper arm on 05/14/2024, indicating that the patch had not been changed as required. The Licensed Practical Nurse (LPN) documented the administration of the patch on 05/10/2024, but the patch was not actually applied due to it not sticking to the resident's chest. The LPN failed to remove the old patch and did not notify the physician of the failure until 05/14/2024. Interviews with the LPN and the Corporate Clinical Specialist confirmed the oversight. The LPN admitted to documenting the administration of the patch without actually applying it and failing to remove the old patch. The Corporate Clinical Specialist acknowledged that the physician should have been immediately notified of the failure to apply the patch. This series of actions and inactions led to the resident not receiving the prescribed medication for hypertension as ordered, constituting a significant medication error.
Failure to Obtain Current Hospice Documentation
Penalty
Summary
The facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services provided for a resident receiving hospice care. The resident had diagnoses including stroke, seizure disorder, and malnutrition, and was admitted to the contracted hospice agency. The facility's agreement with the hospice agency required the hospice interdisciplinary team to review and revise the resident's Plan of Care at least every 15 days and for all communication to be documented in the resident's clinical record. Additionally, the facility was responsible for obtaining the resident's most recent hospice Plan of Care and recertification of terminal illness from the hospice agency. However, the facility did not have any documentation of hospice services from the contracted hospice agency since early April 2024, despite the requirement for regular updates and documentation. The hospice binder contained outdated information, and there was no evidence of attempts by the facility to obtain current hospice documentation. Interviews with the hospice agency's LPN and the facility's DON confirmed the lack of current documentation and indicated that there was no designated staff member responsible for ensuring the hospice documentation was up-to-date.
Failure to Perform Hand Hygiene During Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) completed proper hand hygiene during incontinence and catheter care for a resident. The facility's policy on hand hygiene, reviewed on 01/24/2024, mandates that staff perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site, after contact with bodily fluids, and after removing gloves. Despite this policy, an observation on 05/15/2024 revealed that the CNA did not perform hand hygiene before putting on gloves, after removing soiled gloves, or after completing incontinence and catheter care for the resident. The CNA confirmed in an interview that she did not perform hand hygiene as required during the care process. The resident involved had a urinary catheter, was always incontinent of bowel, and had a recent history of urinary tract infections, including one within the last 30 days for which they were receiving antibiotics. The CNA's failure to perform hand hygiene was observed during the removal of a soiled brief, cleaning of stool from the resident's buttocks, and cleansing of the resident's genitals and catheter tubing. The Corporate Clinical Specialist confirmed that the CNA should have completed hand hygiene during the care process as per the facility's policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident #43, who was admitted with a diagnosis of Alzheimer's disease with late onset. On 04/19/2024, a CNA informed an LPN that Resident #43's left cheek and the left corner of her lip were swollen and red. The LPN assessed the resident and notified the primary care doctor and the Director of Nursing (DON). However, the DON did not document the assessment and did not report the incident to the Administrator. The resident, being severely cognitively impaired, could not explain how the injury occurred. Interviews with the staff revealed that the DON suspected abuse but did not document her assessment or conduct a further investigation. The Administrator was unaware of the incident until the survey. The facility did not produce any documentation indicating that a report for an injury of unknown origin was made, leading to a deficiency in reporting suspected abuse, neglect, or theft as required.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident diagnosed with Alzheimer's disease with late onset. The resident, who had severely impaired cognition, was found with a swollen lip and red cheek by a CNA, who reported it to an LPN. The LPN assessed the resident and notified the primary care doctor and the DON. However, the DON did not document the assessment and did not report the incident to the Administrator. The Administrator was unaware of the incident until the surveyor's interview. Despite the initial assessment by the LPN and the DON, there was no further investigation into the cause of the resident's injuries. The DON confirmed that there was no documentation to support the assessment or any investigation into the injury. The lack of documentation and investigation into the injury of unknown origin constitutes a deficiency in the facility's response to potential abuse or neglect.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
