Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jefferson Healthcare Center during CMS and state inspections, most recent first.
Failure to Notify Cognitively Intact Resident of Care Plan Meeting. A resident who was his own responsible party and cognitively intact was not notified in advance of a care plan conference and was not invited to participate in discussions about his plan of care. Records showed only an unsuccessful attempt to contact a family member, and staff confirmed there was no documented evidence that the resident had been invited or attended the meeting.
Two residents had signed consent for annual flu and pneumococcal vaccines, and physician orders were entered allowing administration, but the electronic record showed no documentation that either vaccine was actually given or why they were not given. One resident was severely cognitively impaired and the other was cognitively intact; the cognitively intact resident stated he wanted the vaccines and had not received any vaccines since admission. The ADON/IP confirmed the vaccines were not administered and could not explain why.
A resident with hemiplegia and hemiparesis, requiring substantial assistance with dressing, was observed wearing the same stained hospital gown for multiple days. Despite receiving a bed bath, the resident was redressed in the same soiled gown, and staff confirmed that clothing should have been changed daily.
Nine staff members, including CNAs and a CNA Supervisor, did not follow proper mechanical lift procedures as outlined by facility policy and the manufacturer's guidelines. Staff were observed and reported locking the caster brakes during resident transfers, instead of leaving them unlocked as required, demonstrating a lack of competency in safe lift operation.
Staff failed to maintain accurate medical records by sharing EMR credentials and documenting care activities under the wrong staff accounts. Multiple CNAs admitted to using each other's logins to record ADLs and other care tasks for several residents, resulting in documentation that did not accurately reflect who provided care or when it was delivered.
A resident with physician orders for insulin and specific blood glucose monitoring experienced multiple episodes of elevated blood glucose. Despite orders to notify the physician for high readings, there was no documentation that the physician was informed of these elevated levels, as confirmed by review of records and interviews with the DON.
A resident with a history of atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers did not receive daily wound care as ordered on multiple occasions. Documentation and staff interviews confirmed that wound care was missed, especially on days when the resident attended dialysis, with no evidence of refusal or physician orders to hold care. Nursing staff and the DON acknowledged the lapses in following wound care orders.
The facility did not consistently ensure that LPNs reconciled and documented controlled substances on all medication carts at shift changes, as required by policy. Multiple shifts lacked signatures from either the off-going or oncoming nurse, and some records were incomplete regarding the total number of controlled medication packages. Staff interviews confirmed awareness of the policy but acknowledged lapses in following it, and the DON verified the documentation was not completed as required.
The facility did not ensure its QA Committee followed through on a corrective action plan to address ongoing deficiencies in narcotic count documentation. Despite a QAPI plan requiring weekly audits and nurse signatures, recurring issues with incomplete and inaccurate narcotic reconciliation persisted, and no disciplinary actions were taken against staff for noncompliance.
The facility did not ensure its QAA committee consistently included the required members, such as the MD, Administrator, DON, and three additional staff, during quarterly meetings. Documentation showed that on multiple occasions, either some required members were absent or not enough staff were present, and the facility could not provide evidence to confirm proper attendance.
Three residents, including those with intact and moderate cognitive status, were unable to access their personal funds on weekends due to limited business office hours and lack of communication about alternative access through the DON. Facility policy required reasonable access, but there was no documentation that residents were informed of weekend procedures or that funds were accessed during that time.
A resident was discharged from Medicare Part A skilled services before benefit days were exhausted, but the required Notice of Medicare Non-Coverage (NOMNC) was not provided to the resident or their responsible party. Facility records and staff interviews confirmed the absence of the NOMNC prior to discontinuation of covered services.
A resident's room was not kept in a sanitary condition, as an unknown dried brown substance remained on the wall next to the bed for several days despite housekeeping staff being responsible for cleaning and disinfecting the area. Multiple staff confirmed the deficiency during surveyor observations and interviews.
The facility did not report an injury of unknown origin involving a resident with severe cognitive impairment, nor did it report an incident of resident-to-resident physical aggression, both of which were required by policy. Leadership interviews confirmed that neither event was reported to the State Survey Agency, and there was a lack of clarity among staff regarding reporting requirements.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the eye, and the facility failed to conduct a thorough investigation as required by policy. The administrator did not document security footage reviews or obtain written staff statements, and key staff were not interviewed about the incident. The lack of documentation and incomplete investigation resulted in a failure to properly address the injury.
A resident was discharged without receiving the required 30-day written notification. Review of records and staff interviews confirmed that the mandated notice was not provided prior to the resident's discharge.
The facility did not make required referrals to the Louisiana PASRR program for two residents—one admitted with Major Depressive Disorder and Bipolar II Disorder, and another who developed Major Depressive Disorder after admission. Staff interviews and record reviews confirmed that PASRR Level II evaluations were not completed or referred for these residents, despite their qualifying mental health diagnoses.
A resident admitted with major depressive disorder and bipolar II disorder did not have these psychiatric diagnoses reflected on their Level I PASRR, which was found to be incomplete and undated. Facility staff confirmed the PASRR was inaccurate and not verified for accuracy or completeness, and no documentation was provided to show a complete PASRR was ever done.
A resident who required total assistance with ADLs did not receive necessary nail care, as evidenced by long, yellowed fingernails with visible debris underneath. Staff confirmed the resident's dependence and acknowledged the need for nail care, but documentation and repeated observations showed the care was not provided.
A carton of Med Plus 2.0 nutritional supplement was left opened and unrefrigerated on a medication cart, remaining available for resident use beyond the manufacturer's recommended 4-hour window. An LPN was unaware of the storage requirement, and the DON confirmed the supplement should have been discarded.
Two residents had inaccurate entries in their electronic Medication Administration Records (eMAR), including documentation of wound care assessments and medication administration that did not actually occur. Staff and leadership confirmed that these records were not truthful or accurate, as required by facility policy and professional standards.
A resident did not receive Nystatin powder as prescribed, due to a misunderstanding by the treatment nurse who thought it was ordered as needed. The medication was not applied on multiple occasions, as confirmed by the DON after reviewing the eMAR.
A resident's insulin order was changed by an LPN from once daily to twice daily without a physician's order. The LPN had not completed the required medication competency assessment, which was overlooked during orientation. The facility failed to ensure the LPN demonstrated competency in clarifying physician orders.
The facility failed to ensure complete and accurate documentation of medication administration records for two residents. One resident's eMAR lacked documentation for medications like Gabapentin and eye drops, while another resident's eMAR was missing records for multiple medications, including Aspirin and Insulin. The DON confirmed these omissions, emphasizing the need for proper documentation.
A facility failed to assess a resident for self-administration of medications, as a cognitively intact resident was found with a medicine cup containing nine pills on their bedside table. The facility's policy requires nurses to ensure residents take their medications and not leave them unattended. An LPN left the medications for the resident to self-administer later, assuming they were taken. The DON confirmed this was against policy, and the resident was not care planned for self-administration.
A resident, who was cognitively intact but required assistance with bathing due to limited range of motion, did not receive scheduled baths over several periods from August to October. Despite being scheduled for baths three times a week, documentation showed gaps in care, and the facility could not provide evidence of bathing during these times. The DON confirmed the oversight.
A resident, who required assistance with bathing, was inaccurately documented as receiving showers, while staff and the resident confirmed only bed baths were provided. The DON acknowledged the documentation error, highlighting a failure to maintain accurate medical records.
The facility failed to ensure fall prevention measures for two high-risk residents. One resident did not have a fall mat or dycem as required, and another did not have a fall mat despite a physician's order. Observations and staff interviews confirmed the absence of these safety measures.
The facility failed to sanitize the thermometer when measuring food temperatures and did not perform hand hygiene during meal service. A culinary cook did not sanitize the thermometer between uses, and a CNA did not wash hands or change gloves while assisting residents with meals. Both actions were confirmed as unacceptable by the culinary manager and the DON.
The facility failed to ensure a resident's room and equipment were kept clean. Observations revealed dried substances on the floor and tube feeding pole, and the resident's wheelchair had labels covered in a dark brown substance. Staff confirmed the unsanitary conditions.
The facility failed to check a resident's PEG tube placement before administering enteral nutritional therapy. An LPN did not auscultate the tube placement as required by the facility's policy, and the Quality Assurance Nurse confirmed this procedure should have been followed.
The facility failed to complete quarterly assessments in a timely manner for seven residents, with assessments completed more than 14 days after the ARD. Staff confirmed the late completion, and validation reports corroborated the findings.
The facility failed to submit resident assessments to CMS in a timely manner for nine residents. The assessments were completed but not transmitted within the required 14-day period, and one assessment was rejected due to an invalid date and not resubmitted promptly. This issue was confirmed through record reviews and staff interviews.
Failure to Notify Cognitively Intact Resident of Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident who was his own responsible party was notified in advance of a care planning conference so he could participate in the meeting for his plan of care. Resident #89 was admitted on 10/11/2024 and had diagnoses including Type II Diabetes, Chronic Obstructive Pulmonary Disease, and Schizoaffective Disorder. The resident’s Quarterly MDS with an ARD of 03/26/2026 showed a BIMS score of 15, indicating he was cognitively intact. During an interview on 04/06/2026, the resident stated he was responsible for his own care and was not aware of, and had not been invited to, a meeting to discuss his plan of care. Review of the Notice of Care Plan Meeting form dated 01/22/2026 showed only an unsuccessful attempt to contact a family member to schedule a care plan meeting, and the resident was not included or made aware of the upcoming meeting. The Social Worker stated there was no documented evidence that the resident had ever been invited to or attended a care plan meeting, and the Administrator stated the resident had not been invited to his quarterly care plan meetings and should have been.
Failure to Administer Consented Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure annual influenza and pneumococcal immunizations were administered after consent had been obtained for two residents. The facility’s policy stated that all residents shall be offered the vaccines and, if consented, administered them, with the information documented in the resident’s electronic immunization record. On 04/07/2026, the Assistant Director of Nursing/Infection Preventionist was asked to provide all influenza and pneumococcal immunization consents and administration records for the two residents. One resident had a BIMS score of 01 and was severely cognitively impaired. That resident’s responsible party signed consent for the annual influenza and pneumococcal vaccines, and a physician order later indicated the resident may receive both vaccines, but the electronic record contained no documentation that either vaccine was administered after consent was obtained and no documentation explaining why they were not given. The second resident had a BIMS score of 14 and was cognitively intact. That resident’s signed consent also indicated the resident was to receive both vaccines, and a physician order was entered allowing administration, but the electronic record again showed no documentation that either vaccine was administered or why they were not administered. The resident stated he wanted the vaccines and reported he had not received any vaccines since admission. The ADON/IP confirmed both residents had consented but were not administered the vaccines and offered no explanation, and the Administrator did not provide additional evidence to dispute the findings.
Failure to Provide Assistance with Dressing for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with hemiplegia and hemiparesis, who required substantial to maximal assistance with dressing, was not provided appropriate assistance with changing clothes. The resident was observed on three consecutive mornings lying in bed wearing the same hospital gown, which had a visible red stain on the left upper chest area. The resident reported that no staff member had changed her clothes since the initial observation and expressed a desire to have her clothes changed. Further investigation revealed that a Certified Nursing Assistant provided a bed bath to the resident but dressed her in the same soiled hospital gown afterward. The Corporate Nurse acknowledged that residents' clothes should be changed daily and that it was inappropriate to redress a resident in the same clothing after a bath. These findings were based on observations, interviews, and record review, confirming that the facility failed to provide necessary assistance with dressing and changing clothes for a dependent resident.
Staff Lacked Competency in Mechanical Lift Operation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides were competent in the operation of mechanical lifts, as required by both facility policy and the manufacturer's guidelines. Specifically, 9 out of 14 staff members investigated, including CNAs and a CNA Supervisor, demonstrated incorrect procedures during resident transfers using the mechanical lift. The facility's policy and the manufacturer's operating manual both specify that the caster brakes of the mechanical lift should remain unlocked when raising a resident from a bed to allow the lift to center itself and increase stability. However, multiple staff members reported and were observed locking the caster brakes during this process. During an observed transfer, staff locked the caster brakes before raising a resident from the bed, contrary to the required procedure. Interviews with several CNAs confirmed their practice of locking the brakes when lifting or lowering residents, indicating a widespread lack of competency in the correct use of the mechanical lift. Supervisory staff and a corporate nurse acknowledged that staff should be following the manufacturer's guidelines, which were not adhered to during the observed and reported incidents.
Inaccurate Resident Records Due to Shared EMR Credentials
Penalty
Summary
Staff failed to ensure the accuracy and integrity of resident medical records for six out of nine residents reviewed. Documentation in the electronic medical record (EMR) showed that staff members recorded care activities such as bed mobility, toileting, bowel and bladder elimination, turning and positioning, and meal consumption for multiple residents. However, interviews revealed that the staff who documented these activities were not always the ones who provided the care. For example, one CNA's credentials were used by others to document care provided to residents, and another CNA admitted to using a colleague's credentials because she had forgotten her own. Additionally, a CNA was documented as providing a bed bath to a resident on a specific date, but in an interview, she stated she did not care for that resident on that day, and another CNA confirmed she had provided the care but used someone else's credentials to document it. Further interviews with staff, including CNAs and supervisory personnel, confirmed that sharing EMR credentials and documenting under another staff member's login was occurring. The corporate nurse and CNA supervisor both acknowledged that staff credentials should remain confidential and that staff should not document in the EMR using another person's credentials. These actions resulted in inaccurate and unreliable resident records, as the documentation did not accurately reflect who provided care or when it was provided.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels as required by the resident's physician orders. The orders specified that the physician should be called if the resident's blood glucose level was between a certain range, but review of the electronic Medication Administration Record (eMAR) showed several instances where the resident's blood glucose levels were significantly elevated, ranging from 360 mg/dL to 433 mg/dL. Despite these elevated readings, there was no documented evidence that the physician was notified as directed by the orders. Interviews with the Director of Nursing confirmed that nursing staff were expected to notify the physician for any blood glucose level above 352 mg/dL, but the facility was unable to provide documentation that such notifications occurred for the elevated readings identified. This deficiency was identified for one resident out of five sampled for unnecessary medications, based on both record review and staff interviews.
Failure to Provide Ordered Daily Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to follow physician's orders to provide daily wound care for a resident with unhealed pressure ulcers. Review of the resident's medical record and electronic Medication Administration Record (eMAR) showed that wound care orders, including cleaning and dressing of wounds on the left heel, left great toe, left hip, and sacrum, were not performed on multiple documented dates. There was no evidence in the progress notes that wound care was provided or refused on these dates, and no documentation was available to justify the missed care, such as holding wound care due to dialysis appointments. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident did not receive wound care as ordered on several days, particularly when the resident was out of the facility for dialysis. The staff acknowledged that there were no orders to hold wound care and that care should have been provided before or after dialysis. The resident's medical history included conditions such as atrial fibrillation, peripheral vascular disease, and unhealed pressure ulcers, and the Braden Scale assessment indicated a risk for skin breakdown.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all five medication carts reviewed. According to the facility's policy, both the off-going and oncoming nurses are required to count and document the controlled substances at each shift change, with signatures from both parties on the Controlled Drug Count Record and Package Inventory form. However, multiple instances were identified where either the off-going or oncoming nurse, or both, did not sign the required documentation for various shifts and dates across all medication carts (a through e). In some cases, the total number of controlled medication packages reconciled was also not documented. Record reviews revealed that for numerous shifts, there was no documented evidence that the required reconciliation and documentation of controlled substances occurred. This included missing signatures and incomplete records for both the receipt and disposition of controlled drugs. The facility was unable to provide any additional documentation to demonstrate that the reconciliation process was completed as required by their policy. Interviews with nursing staff confirmed that they were aware of the requirement to reconcile and document controlled substances at each shift change, but admitted to not completing the process as required on specific occasions. The Director of Nursing also confirmed that the Controlled Drug Count Record and Package Inventory sheets were not completed with the necessary signatures at the beginning and/or end of shifts as required.
Failure to Implement QA Plan for Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively implemented a developed plan of action to address identified quality deficiencies related to accurate narcotic count documentation. Despite creating a Quality Assurance Performance Improvement (QAPI) plan that included weekly audits of medication carts and required nurse signatures, recurring problems with incomplete and inaccurate narcotic reconciliation documentation persisted. The Director of Nursing confirmed that, although the issue was identified and interventions such as staff discipline were outlined, no disciplinary actions were taken against nursing staff for ongoing noncompliance, and the documentation issues continued to be observed during the survey.
QAA Committee Lacked Required Members and Attendance at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee was composed of all required members and met at least quarterly, as outlined in its own policy and procedure. According to the facility's policy, the QAA committee should include the Medical Director (MD), the Administrator, the Director of Nursing (DON), and three other staff members designated by the facility. Review of the QAA meeting minutes and sign-in sheets for three separate quarterly meetings revealed that the required composition of the committee was not consistently met. On one occasion, only the DON, Administrator, Dietary Manager, and MD were present, with no evidence of additional staff. On another occasion, the MD and Administrator were absent, and on a third occasion, only the DON, Administrator, and MD were present, again lacking additional staff members. The facility was unable to provide any additional documentation to demonstrate that the required members attended the QAA meetings on the reviewed dates. An interview with the DON confirmed that no further evidence was available to show compliance with the committee composition requirements for those meetings. No information about residents or their medical conditions was included in the report.
Failure to Ensure Resident Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents were able to access and manage their personal funds at all times, as required by policy. Three residents, including two who were cognitively intact and one with moderate cognitive impairment, reported being unable to access their funds on weekends. The facility's policy stated that residents should have reasonable access to their funds and that requests for fifty dollars or less would be honored the same day. However, interviews revealed that the business office was only open for banking hours Monday through Friday, and while a petty cash box was left with the weekend DON, this information was not communicated to residents. There was no documented evidence that residents were informed about how to access their funds on weekends, nor was there documentation that any residents had actually accessed their funds during that time. Staff interviews confirmed that the process for weekend access was not publicized, and the facility lacked records showing that residents were notified of banking hours or that this was discussed during care plan meetings or resident council meetings. The administrator acknowledged that while funds were technically available on weekends, there was no documentation to support this or to show that residents were aware of the process.
Failure to Provide Required Medicare Non-Coverage Notice Prior to Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare Part A skilled services before exhausting their benefit days. The resident began receiving Medicare Part A skilled services on 09/23/2024, with the last covered day being 11/03/2024. The facility initiated the discharge from Medicare Part A services, but there was no documented evidence that the required NOMNC was given to the resident or their responsible party prior to the discontinuation of covered services and discharge home. Record review and staff interviews confirmed that the NOMNC was not located or completed for the resident, and the facility was unable to provide documentation that the notice was issued as required. The Social Services Director acknowledged the absence of the NOMNC, and the Administrator confirmed that the facility had identified issues with beneficiary notifications but had not yet implemented a quality assurance process to address the problem.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in a resident's room, as evidenced by repeated observations of an unknown dried brown substance on two areas of the wall next to the resident's bed. This substance was noted on four consecutive days during surveyor observations, indicating that the issue persisted over time and was not addressed despite ongoing housekeeping responsibilities. Interviews with the housekeeper responsible for the room revealed that she claimed to have cleaned and wiped all unclean areas, yet the substance remained present during a joint observation. Additional staff, including a business office specialist and the facility administrator, confirmed that the wall was not maintained in a sanitary manner at the time of the observations. The facility's own housekeeping job description required cleaning and disinfecting walls, but this standard was not met in this instance.
Failure to Report Injury of Unknown Origin and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report two separate incidents as required by its Abuse Prevention and Prohibition policy. In the first incident, a resident with severe cognitive impairment was found with a bruise of unknown origin to the right periorbital area. The resident was unable to provide a history of the injury, and there was no documented evidence of a witnessed fall or explanation for the bruise. Despite the lack of a known cause, the administrator and regional administrator did not submit a report to the State Survey Agency, as required for injuries of unknown origin. In the second incident, another resident with severe cognitive impairment was physically pulled from a wheelchair and yelled at by another resident. This event was documented in the facility's incident log and nurse's notes, but there was no evidence that the incident was reported to the State Survey Agency as an allegation of resident-to-resident abuse. Interviews with facility leadership confirmed that the incident was not reported, and there was uncertainty among staff about whether the event constituted a reportable allegation of abuse.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a reddish-blue bruise around the right eye, and was unable to provide a history of the injury. The facility's abuse prevention policy required a comprehensive investigation, including interviews and signed statements from all staff involved, as well as interviews with the resident or their roommate if the resident was unable to communicate. However, the administrator only spot-checked security footage without documenting the review, and did not obtain or document written statements from staff. The CNA Supervisor reported conducting only verbal interviews with two CNAs, but did not document these interviews, and both CNAs later stated they were not interviewed or asked for statements. Additionally, an LPN who was notified of the bruise was not interviewed about the incident. The administrator assumed the injury was caused by a fall, despite no documented falls for the resident, and did not interview staff from other shifts or obtain further evidence. There was no documented evidence to show that a thorough investigation, as required by facility policy, was completed regarding the resident's injury. The lack of documentation and incomplete staff interviews resulted in a failure to properly respond to and investigate the injury of unknown origin.
Failure to Provide 30-Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30-day written notice prior to the discharge of a resident. Review of the electronic medical record showed that the resident was discharged on 02/05/2025 at 3:33PM, but there was no documented evidence that the resident received the mandated 30-day notification before discharge. Interviews with the Social Service Director and the Administrator confirmed that the resident did not receive the 30-day written notification prior to being discharged.
Failure to Refer Residents with Mental Illness for PASRR Evaluation
Penalty
Summary
The facility failed to ensure that referrals were made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for two residents with mental illness diagnoses. One resident was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder, but there was no documented evidence that a PASRR Level II evaluation was completed or a referral was made to the PASRR program. Another resident developed a diagnosis of moderate, recurrent Major Depressive Disorder after admission, yet there was also no documentation of a PASRR Level II evaluation or referral for this new diagnosis. Interviews with facility staff confirmed that both residents met criteria requiring a PASRR Level II referral, either due to admission with a mental illness or the onset of a qualifying diagnosis after admission. Record reviews and staff statements indicated that these referrals were not identified or completed during routine audits or at the time of diagnosis, resulting in a failure to coordinate necessary assessments and referrals as required.
Failure to Accurately Complete PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a complete and accurate Level I Pre-Admission Screening and Resident Review (PASRR) was conducted for a resident admitted with diagnoses of major depressive disorder and bipolar II disorder. Record review showed that the resident's Level I PASRR was incomplete, undated, and did not identify any mental illness diagnosis, despite the resident's documented psychiatric conditions. Interviews with facility staff confirmed that the PASRR was inaccurate and incomplete, and there was no documented evidence that a complete Level I PASRR was ever completed or verified for accuracy and completeness for this resident.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A dependent resident who required total assistance with activities of daily living (ADLs) did not receive appropriate nail care. Review of the care task log showed that the resident's nail care was marked as not applicable on the morning of the observed date. Multiple observations throughout the day revealed that all ten of the resident's fingernails were yellowed, extended one-fourth to one-half inch beyond the fingertips, and had an unknown gray substance visible underneath. The resident expressed a desire to have his fingernails cut. Staff interviews confirmed that the resident required total assistance with ADLs, and the Assistant Director of Nursing acknowledged that the resident's nails needed to be cut and cleaned. The repeated observations and documentation review indicated that the facility failed to provide necessary nail care and assistance for this dependent resident.
Improper Storage and Availability of Nutritional Supplement
Penalty
Summary
A carton of Med Plus 2.0 nutritional supplement was found opened and unrefrigerated on a medication cart, with the opened date marked as the previous day. According to the manufacturer's guidelines, the supplement should be used within 4 hours of opening if not refrigerated. Observation confirmed that the supplement was still available for resident consumption well beyond the recommended time frame. An LPN acknowledged not knowing the requirement to discard the supplement after 4 hours if not refrigerated, and the DON confirmed that the supplement should not have been available for use under these conditions.
Inaccurate Documentation in eMAR for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic Medication Administration Record (eMAR) for two residents. For one resident with a history of unhealed pressure ulcers and who was cognitively intact, the eMAR and wound care assessment indicated that a wound care nurse evaluated and treated the resident's wounds on a specific date. However, both the resident and the nurse confirmed that no such evaluation or treatment occurred on that date, and the nurse could not explain why the documentation was inaccurate. Facility leadership, including the Director of Nursing and a corporate nurse, confirmed the documentation was incorrect and should not have been entered as such. For another resident who was admitted to a hospital and later returned to the facility, the eMAR showed that multiple medications and care tasks were documented as completed during the resident's absence from the facility. These included administration of eye drops, tube feedings, repositioning, and other nursing interventions, all recorded as performed by specific LPNs. Interviews with staff confirmed that medications and tasks should only be documented if actually performed, and the Director of Nursing acknowledged that the eMARs should have been accurate and not indicated completion of tasks that did not occur.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident, leading to a deficiency in pharmaceutical services. The resident was prescribed Nystatin powder to be applied to the right abdominal fold twice daily and as needed. However, a review of the electronic Medication Administration Record (eMAR) for September 2024 revealed multiple instances where the medication was not applied as scheduled. Specifically, the Nystatin powder was not administered at 8:00 a.m. on one occasion and at 4:00 p.m. on numerous dates throughout the month. Interviews conducted with the treatment nurse and the Director of Nursing (DON) confirmed the oversight. The treatment nurse mistakenly believed the Nystatin powder was ordered only as needed, which led to the medication not being applied as per the physician's orders. The DON verified that the medication was indeed ordered to be applied twice daily and as needed, acknowledging the failure to adhere to the prescribed regimen on the documented dates.
LPN Changes Insulin Order Without Physician's Approval
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) demonstrated competency in clarifying a physician's order for a medication change. Specifically, an LPN altered a resident's Tresiba insulin order from 30 units once daily to 30 units twice daily without obtaining a physician's order. This change was made despite the resident's care plan indicating that medications should be administered as ordered by the physician. The lack of documented evidence of a physician's order for this change was confirmed through record reviews and interviews. The deficiency was further compounded by the fact that the LPN responsible for the medication change had not completed the competency assessment for medications during their orientation. This oversight was acknowledged by the Assistant Director of Nursing, who admitted to overlooking the completion of the medication competency. The Director of Nursing confirmed that the medication order should not have been changed without a physician's order and acknowledged the incomplete competency assessment for the LPN involved.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to ensure that medication administration records were complete and accurately documented for two of the three residents sampled. For Resident #1, the October 2024 Physician's Orders included medications such as Gabapentin, artificial tears, and Prednisolone-Moxifloxacin-Bromfenac eye drops. However, the electronic Medication Administration Record (eMAR) lacked documented evidence of administration for these medications on specific dates. The Director of Nursing (DON) confirmed these omissions and stated that all medications should have been documented as administered or noted with the appropriate chart code if not administered. Similarly, for Resident #2, the October 2024 Physician Orders included multiple medications such as Aspirin, Ferrous Sulfate, Folic Acid, Insulin Glargine, Levothyroxine Sodium, Norvasc, Zoloft, Fluoxetine HCl, Senna, and Insulin Aspart. The eMAR did not show documented evidence of administration for these medications on specified dates. The DON confirmed these omissions as well, indicating that all medications should have been documented when administered or as applicable.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as evidenced by an incident involving a cognitively intact resident with a Brief Interview for Mental Status score of 15. The facility's Med Pass Guidelines policy, dated 12/04/2017, stipulates that nurses should not leave medications with residents in a cup and must ensure that residents take their medications. However, during an observation, a medicine cup containing nine pills was found on the resident's bedside table. The resident confirmed that an LPN left the pills for self-administration later. The LPN admitted to assuming the resident took the medications while she was present and acknowledged that she should have ensured the medications were taken before leaving the room. The Director of Nursing confirmed that the LPN should not have left medications at the resident's bedside, and the resident was not care planned to have medications at the bedside.
Failure to Provide Scheduled Baths to Resident
Penalty
Summary
The facility failed to provide a dependent resident with scheduled baths, as required by their care plan and the facility's Bed Bath Policy and Procedure. The resident, who was cognitively intact but had limitations in range of motion in both upper and lower extremities, required partial to moderate staff assistance with bathing. Despite being scheduled for baths on Mondays, Wednesdays, and Fridays, the resident reported not receiving a bath for weeks. Documentation from August to October 2024 revealed multiple periods where the resident was not provided a bath, specifically from August 5 to August 9, August 17 to August 26, August 29 to September 3, and October 3 to October 6. The facility was unable to provide any documented evidence that the resident received a bath during these times. The Director of Nursing confirmed the lack of documentation and acknowledged that the resident should have been provided baths according to the schedule.
Inaccurate Bath Documentation for Resident
Penalty
Summary
The facility failed to accurately document the type of bath provided to a resident, leading to a deficiency in maintaining accurate medical records. The resident, who was cognitively intact and required partial to moderate staff assistance with bathing due to limitations in range of motion, was documented as having received showers on multiple occasions in August 2024. However, interviews with the resident and staff, including CNAs and the shower aide, confirmed that the resident only received bed baths and did not take showers. The discrepancy in documentation was acknowledged by the Director of Nursing, who confirmed that the bath records should have accurately reflected the type of bath the resident received. This inaccuracy in documentation was identified during a review of the resident's care plan and bath log, highlighting a failure to adhere to accepted professional standards in maintaining medical records.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention measures were in place for two residents identified as high risk for falls. Resident #44, who had moderate cognitive impairment and a history of unwitnessed falls, did not have a fall mat at his bedside or a dycem in his wheelchair as required by his care plan. Multiple observations confirmed the absence of these safety measures, and interviews with staff revealed a lack of awareness or adherence to the resident's fall prevention interventions. Similarly, Resident #98, diagnosed with Parkinsonism, lack of coordination, and muscle weakness, did not have a fall mat at the bedside despite a physician's order and a high fall risk assessment. Observations over several days confirmed the absence of the fall mat, and staff interviews indicated that the fall mat was not consistently in place. The Director of Nursing confirmed that both residents should have had the specified fall prevention measures in place at all times.
Failure to Sanitize Thermometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to sanitize the thermometer when measuring internal food temperatures and did not perform hand hygiene during meal service. Specifically, a culinary cook did not sanitize the thermometer before and between measuring the temperatures of various foods, including pureed cauliflower, lasagna, broccoli, brown gravy, and chicken noodle soup. The cook used a dishtowel and paper towels to wipe the thermometer instead of sanitizing it, and even dropped the thermometer into the chicken noodle soup without disposing of the contaminated soup. The culinary manager confirmed that the cook's actions were not acceptable and did not follow proper sanitization procedures. Additionally, a CNA failed to perform hand hygiene while assisting residents with meal distribution. The CNA did not wash hands before or after handling food trays, opening drinks, unwrapping utensils, or assisting residents in various rooms. The CNA also used the same gloves to handle multiple food trays and residents without changing them or performing hand hygiene. Both the CNA and the Director of Nursing acknowledged that the observed practices did not adhere to the facility's hand hygiene policy and were unacceptable.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a resident's room and equipment were kept clean for one of the four residents reviewed for environment. Observations on three consecutive days revealed large areas of a dried tan substance on the floor near the resident's tube feeding pole and on the base of the tube feeding pole. Additionally, the resident's wheelchair had two law labels covered in a dark brown substance. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the resident's floor, tube feeding pole, and wheelchair were not sanitary and should have been kept clean.
Failure to Check PEG Tube Placement Before Feeding
Penalty
Summary
The facility failed to check the placement of a resident's PEG tube prior to administering enteral nutritional therapy. Specifically, an LPN did not auscultate the tube placement before administering a bolus feeding to a resident diagnosed with dysphagia and gastrostomy status. The facility's policy required checking the tube's position by listening for air movement in the stomach, but this step was not followed. The deficiency was observed during an inspection, where the LPN admitted to not performing the required auscultation before administering the feeding. The resident's care plan also specified the need to check the tube placement before feedings, which was not adhered to. The Quality Assurance Nurse confirmed that the procedure should have been followed as per the facility's policy.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to complete quarterly assessments in a timely manner for seven residents. The assessments for these residents were completed more than 14 days after the Assessment Reference Date (ARD), which is not in compliance with the required timeline. Specifically, the assessments for Resident #45, Resident #56, Resident #74, Resident #88, Resident #132, Resident #149, and Resident #164 were all completed late, with completion dates ranging from 18 to 39 days after the ARD. During interviews, both the MDS Nurse and the Director of Nursing confirmed that the assessments were completed late and acknowledged that they should have been completed within the required timeframe. The facility's Final Validation Reports also confirmed the late completion of these assessments. This deficiency was identified through record reviews and staff interviews, highlighting a failure in the facility's process for timely resident assessments.
Failure to Submit Resident Assessments Timely
Penalty
Summary
The facility failed to submit resident assessments to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for nine residents. The assessments for these residents were completed but not transmitted within the required 14-day period. Specifically, the assessments for Resident #6, Resident #20, Resident #92, Resident #103, Resident #120, Resident #130, Resident #147, Resident #162, and Resident #170 were all submitted late, with delays ranging from several days to over a month past the completion date. Additionally, Resident #130's assessment was rejected by CMS due to an invalid date and was not resubmitted in a timely manner. This issue was confirmed through record reviews and interviews with facility staff, including the MDS Nurse and the Director of Nursing, who acknowledged the delays and the failure to meet the submission requirements. The deficiencies were identified during a review of the facility's Final Validation Reports and interviews with staff members. The MDS Nurse was unaware of the rejection of Resident #130's assessment and confirmed that the other assessments were submitted late. The Director of Nursing also confirmed the late submissions. These findings indicate a systemic issue with the timely submission of resident assessments, which is a critical regulatory requirement for ensuring accurate and up-to-date resident information is available to CMS.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ochsner Medical Center Skilled Nursing Facility | 0.4 mi | ★★★★★ | 0 | 0 |
| Chateau De Notre Dame Community Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| St Anthony Community Care Center | 2.9 mi | ★★★★★ | 9 | 0 |
| John J Hainkel Jr Home And Rehabilitation Center | 3.3 mi | ★★★★★ | 1 | 0 |
| Covenant Home | 3.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.