Lakeview Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Roads, Louisiana.
- Location
- 400 Hospital Road, New Roads, Louisiana 70760
- CMS Provider Number
- 195446
- Inspections on file
- 19
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakeview Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a PEG tube was not administered the correct amount of enteral feeding as ordered, receiving only one can of Diabetisource instead of the prescribed two cans at meals. The nursing staff acknowledged the error after it was highlighted during a survey, indicating a lapse in following the resident's care plan.
A resident with a PEG tube was not administered the correct amount of enteral feeding as per physician's orders, leading to a deficiency in care. The nurse failed to verify the orders and inaccurately documented the administration, providing only one can of Diabetisource instead of the prescribed amount. The DON confirmed the orders were not followed, resulting in a failure to meet professional standards of quality.
A resident with a PEG tube experienced significant weight loss due to the facility's failure to administer the prescribed amount of enteral feedings. Despite orders for more than one can of Diabetisource per feeding, the resident was only receiving one can, leading to a caloric deficit. Staff interviews confirmed the oversight, and the resident's weight loss was attributed to not receiving the correct feeding amounts.
The facility failed to store drugs and biologicals properly, with expired supplements found in a medication room and cart, insulin pens lacking open dates, and loose pills on a cart. An LPN and RN confirmed these issues, and the DON acknowledged the expectations for proper labeling and disposal.
The facility failed to meet food service safety standards, with issues such as undated and improperly stored food items, and staff not wearing beard restraints. Observations included undated opened food, improperly stored raw eggs, and unsealed vegetables. Staff confirmed these deficiencies, affecting 97 residents.
A resident reported feeling scared of her roommate, who made threatening statements. Despite the facility's policy requiring immediate reporting of abuse allegations, staff did not report the incident to administration or the state agency within the required timeframe. The staff were aware of the resident's history of aggressive verbal behavior but did not report it, believing the resident could not physically harm others. The administrator confirmed the behavior as abuse but did not report it, leading to a deficiency in compliance with federal reporting requirements.
A facility failed to complete a comprehensive MDS assessment for a newly admitted resident within the required 14-day timeframe. The resident's admission MDS assessment was still in progress beyond the deadline, as confirmed by staff interviews, indicating a lapse in meeting regulatory requirements for timely assessments.
The facility failed to ensure accurate resident assessments, leading to errors in coding discharge and ostomy status for two residents. One resident was incorrectly coded as discharged to a hospital instead of home, and another was inaccurately coded as having no ostomy despite having a colostomy. These discrepancies were confirmed by staff upon review.
A resident with cognitive impairment exhibited new aggressive behaviors, including threats of violence, which were not documented or reported by staff. The care plan was not updated to reflect these changes, despite staff awareness of the behaviors.
A resident with Cerebral Infarction and Hemiplegia, dependent on staff for ADLs, did not receive scheduled daily morning bed baths over several days due to miscommunication among CNAs regarding shift responsibilities. The Nursing Assignment Binder indicated the resident's need for daily bed baths, but confusion persisted about whether day or night shift staff were responsible, leading to the oversight.
A resident with a history of falls experienced a deficiency in fall prevention measures due to inadequate interventions. Despite being at risk for falls, the facility placed a wedge on the left side of the bed, causing the resident to roll towards a hazardous gap on the right side. Staff confirmed the inappropriate intervention and hazardous bed position, leading to the deficiency.
A nurse in an LTC facility failed to verify and administer the correct amount of enteral feeding for a resident with a PEG tube, consistently providing only one can instead of the prescribed amount. Additionally, the nurse did not adhere to Enhanced Barrier Precautions by failing to wear a gown during feeding tube care. The DON confirmed that the nurse's competencies were not adequately assessed, and there was no process to track nursing skills.
A facility failed to ensure staff used appropriate PPE during care for a resident requiring Enhanced Barrier Precautions. A nurse did not wear a gown while providing tube feeding to a resident with a PEG tube, contrary to the facility's policy requiring gown and gloves for such care. Interviews revealed a misunderstanding of the policy, leading to the deficiency.
A resident with severe cognitive impairment experienced a significant change in condition, including vomiting and feeling unwell. Despite facility policy requiring notification, the resident's representative and family were not informed. Staff interviews confirmed the lack of documentation and notification, indicating a deficiency in the facility's procedures.
A resident with severe cognitive impairment experienced a change in condition, including vomiting, which was not documented by the nursing staff. Despite notifying a nurse practitioner and administering Zofran, these actions were not recorded in the resident's medical records, contrary to the facility's documentation policies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter, as an LPN did not wear a gown during catheter care despite posted instructions. The resident had a urinary tract infection and an indwelling catheter. The LPN was unclear about the gown requirement, and the DON confirmed the lapse in protocol adherence.
The facility failed to ensure accurate MDS assessments for two residents, one with Schizophrenia and another with dementia and fall risk, leading to incorrect documentation of PASRR Level II status and bed alarm usage.
The facility failed to maintain a record of the Level 1 PASRR form in a resident's medical record. The resident, admitted with multiple mental health diagnoses, did not have the required PASRR documentation. Staff interviews confirmed that the corporate outreach team and discharging hospital were responsible for the PASRR, but the facility did not verify its inclusion in the preadmission packet.
A facility failed to provide adequate supervision for a fall-risk resident, resulting in multiple falls. Despite a care plan requiring 2-hourly checks, staff did not adhere to this schedule, as confirmed by video footage and staff interviews.
The facility failed to ensure proper infection control practices by not requiring a CNA to wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions (EBPs) due to a peg tube. The CNA confirmed the oversight, and the DON acknowledged the requirement for appropriate PPE.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident requiring enteral feeding. The resident, who was admitted with diagnoses including Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was ordered to receive specific amounts of Diabetisource AC via PEG tube at designated times. However, observations and interviews revealed that the resident was not administered the correct amount of enteral feeding as per the physician's orders. Specifically, the resident was supposed to receive two cans of Diabetisource at breakfast, lunch, and dinner, but was only given one can during an observed feeding. Interviews with the nursing staff and the Director of Nursing confirmed that the resident's tube feeding orders had been frequently changed, but at no point was the resident ordered to receive only one can of the formula. The nurse responsible for the feeding admitted to not administering the correct amount until the error was pointed out during the survey. This oversight in following the prescribed feeding regimen indicates a failure in executing the resident's care plan as ordered, potentially impacting the resident's nutritional status.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that a resident received enteral feeding services as outlined in their comprehensive care plan, which did not meet professional standards of quality. Specifically, the facility did not verify the physician's orders prior to the administration of enteral feeding for a resident with a PEG tube. The resident, who had diagnoses including Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was at risk for malnutrition and was on a NPO status. The care plan required the resident to receive specific amounts of Diabetisource at designated times, but these orders were not followed. The nurse, identified as S6RN, failed to administer the correct amount of enteral feeding as per the physician's orders. Despite the orders specifying multiple cans of Diabetisource at each meal, S6RN consistently administered only one can per feeding. This discrepancy was confirmed through interviews and a review of the resident's Medication Administration Records (MARs), which inaccurately documented the administration of the tube feeding as ordered. S6RN admitted to not verifying the tube feeding orders prior to administration and acknowledged the inaccuracies in the documentation. The Director of Nursing (DON) confirmed that the resident was always ordered to receive more than one can of Diabetisource at each meal and that the nurses should have administered the tube feeding as ordered. The DON also confirmed that S6RN should have verified the tube feeding order before administration and should not have documented the administration inaccurately. This failure to adhere to the care plan and physician's orders resulted in a deficiency in the quality of care provided to the resident.
Failure to Administer Prescribed Enteral Feedings
Penalty
Summary
The facility failed to ensure that a resident received the prescribed enteral feedings, leading to significant weight loss. Resident #53, who had a diagnosis of Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia, was admitted with a PEG tube for nutrition. The resident's clinical records indicated a significant weight loss of 5% or more in the last month and 10% or more in the last six months, despite not being on a physician-prescribed weight loss regimen. The resident was supposed to receive more than one can of Diabetisource per feeding, but observations and interviews revealed that the resident was only receiving one can per feeding, contrary to the physician's orders. Interviews with the staff, including the RN, RD, DON, and NP, confirmed that the resident's tube feeding orders were not followed correctly. The RN admitted to administering only one can of Diabetisource instead of the prescribed amount, which was supposed to be 1.5 cans initially and later increased to two cans per feeding. The RD and NP confirmed that the resident's weight loss could be attributed to not receiving the correct amount of tube feeding, as the resident was receiving 900 kilocalories less than recommended. The DON acknowledged that the nurses should have administered the correct amount of tube feeding as ordered, and the NP confirmed that the incorrect feeding amounts could have contributed to the resident's weight loss.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, leading to several deficiencies. In one of the medication rooms (MR3), eight containers of liquid supplements were found to be expired. This was confirmed by an LPN during an observation. Additionally, a medication cart (MC3) contained expired bottles of Thiamin Vitamin B-1, Aspirin, Melatonin, Magnesium Oxide, and two containers of liquid supplements, all of which were confirmed to be expired by the same LPN. Further deficiencies were observed in another medication cart (MC1), where multiple insulin pens and a multi-dose insulin vial were found without open dates, making it impossible to determine when they were first used. This was confirmed by an RN, who acknowledged that insulin should be marked with an open date. Additionally, the same cart contained several loose pills, which were also confirmed by the RN as inappropriate. The Director of Nursing (DON) stated that she expected nurses to label insulin pens and vials with open or discard dates and confirmed that expired supplements and over-the-counter drugs should be discarded, and no loose pills should be present on medication carts.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several deficiencies were noted, including the lack of proper dating on opened food items such as hot dogs, mustard, mayonnaise, pickles, relish, and ranch dressing. Additionally, sandwiches were found partially covered with torn aluminum foil, and beverages were stored beyond the recommended time frame. In the walk-in cooler, raw eggs were improperly stored above butter and heavy whipping cream, posing a risk of contamination. In the walk-in freezer, cases of chicken and pork loin were stored on the floor, and several bags of vegetables were found opened, unsealed, and undated. The dry storage area also contained bulk containers and partially used food items without identification labels or opened dates. Furthermore, the facility did not ensure that staff with facial hair wore appropriate restraints, as observed when a staff member walked through the food preparation area without a beard restraint. Interviews with staff confirmed these observations and acknowledged the failure to comply with the facility's policies regarding food storage, labeling, and staff attire. These practices had the potential to affect the 97 residents who received nourishment from the facility's kitchen.
Failure to Report Verbal Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of verbal abuse to the State Survey Agency within the required timeframe for a resident who was reviewed for abuse. The facility's policy mandates that any alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. In this case, a resident reported feeling scared of her roommate, who had made threatening statements such as 'I'll shoot you with a gun.' Despite these threats, the staff did not report the incident to the administration or the state agency within the specified timeframe. Interviews with staff revealed that the resident who made the threats had a history of confusion and aggressive verbal behavior, including cursing and making threats to other residents and staff. The staff, including an LPN and CNAs, were aware of these behaviors but did not report them, believing the resident could not physically harm others. The administrator confirmed that such behavior would be considered abuse but did not report it to the state agency, as he believed the resident did not know what she was doing. This inaction led to a deficiency in the facility's compliance with federal requirements for reporting abuse allegations.
Failure to Complete Timely MDS Assessment for New Admission
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe. Resident #195 was admitted to the facility, and their admission MDS assessment, with an Assessment Reference Date (ARD) of 02/25/2025, was still marked as in progress as of 03/10/2025. This was confirmed during an interview with S3MDS, who acknowledged that the assessment had not been completed in the required timeframe. Additionally, S2DON confirmed that the MDS should have been completed within the specified period, indicating a lapse in adhering to the regulatory requirements for timely assessments.
Inaccurate Resident Assessments in Discharge and Ostomy Status
Penalty
Summary
The facility failed to ensure accurate resident assessments, leading to discrepancies in the coding of discharge and ostomy status for two residents. Resident #94 was discharged from the facility on February 15, 2025, and the MDS Discharge Assessment inaccurately indicated a discharge to an acute hospital, while the nurse's notes confirmed the resident was discharged home with family. This error was confirmed by S7MDS upon review of the resident's medical record. Additionally, Resident #22, who was admitted with a medical diagnosis of Colostomy Status, was inaccurately coded in the MDS Quarterly Assessment as having no bowel and bladder appliances, despite having a colostomy. This discrepancy was observed during colostomy care and confirmed by S7MDS upon review of the assessment. S2DON also confirmed that all MDS assessments should have been coded accurately, indicating a failure in the facility's assessment process.
Failure to Update Care Plan for Resident's New Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to reflect new aggressive behaviors. The resident, who was moderately cognitively impaired and had a history of physical and verbal aggressive behaviors, exhibited new threatening behaviors, including making threats of violence with a knife or gun. These behaviors were not documented in the resident's care plan or nurses' notes, and the care plan was not updated to include interventions for these new behaviors. Interviews with staff revealed that the resident's aggressive behaviors were known to some staff members, but they were not reported to administration or documented appropriately. The staff, including CNAs and an LPN, were aware of the resident's verbal threats but did not take the necessary steps to update the care plan or notify the administration. The MDS coordinator and the Director of Nursing confirmed that they were unaware of the new behaviors and acknowledged that the care plan should have been updated to address these changes.
Failure to Provide Scheduled Bed Baths to Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, Resident #47, who was admitted with diagnoses including Cerebral Infarction and Hemiplegia, was dependent on staff for showering and bathing. Despite being scheduled for daily morning bed baths, the resident did not receive these services on multiple consecutive days in March 2025. Interviews with staff revealed a lack of clarity and communication regarding the responsibility for providing bed baths. While the Nursing Assignment Binder indicated that Resident #47 was to receive daily morning bed baths, there was confusion among the CNAs about whether day or night shift staff were responsible for this task. This miscommunication resulted in the resident not receiving the scheduled bed baths, as confirmed by the Director of Nursing and the staff responsible for creating the shower/bed bath schedules.
Inadequate Fall Prevention Measures Lead to Deficiency
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, leading to a deficiency in accident hazard prevention. The resident, who was admitted with diagnoses including cerebral infarction and hemiplegia, was at risk for falls and required maximum assistance for bed mobility. Despite a previous fall from bed, the facility's intervention of placing a wedge on the left side of the bed was inadequate, as it caused the resident to roll to the right, where there was a hazardous gap between the bed and the wall. This gap was identified as an accident hazard, yet no alternative bed positions were attempted to mitigate the risk. Observations and interviews revealed that the resident's bed was positioned diagonally in the room, creating a space on the right side that contributed to the fall. Staff interviews confirmed the inappropriate intervention and the hazardous bed position. The Director of Nursing acknowledged the inadequacy of the intervention, and the Administrator was unaware of the bed's position, confirming that the intervention would not prevent future falls. The facility's failure to address the bed positioning and implement effective fall prevention measures directly led to the deficiency.
Deficiency in Nurse Competency and Adherence to Precautions
Penalty
Summary
The facility failed to ensure that a registered nurse (S6RN) possessed the necessary competencies and skills to care for residents as outlined in their care plans. Specifically, S6RN was unable to verify and administer enteral feedings as ordered by the physician for a resident with a PEG tube. The resident was prescribed more than one can of Diabetisource per feeding, but S6RN consistently administered only one can without verifying the order. This discrepancy was confirmed through interviews and record reviews, revealing that S6RN had never administered the correct amount of tube feeding since the resident began receiving it. Additionally, S6RN failed to adhere to Enhanced Barrier Precautions when providing care to the same resident. Despite the resident being on Enhanced Barrier Precautions, which required the use of gloves and a gown for high-contact activities such as feeding tube care, S6RN did not don a gown during the procedure. This was observed and confirmed during interviews, where S6RN demonstrated a lack of understanding of the precautions required. The Director of Nursing (S2DON) acknowledged that S6RN had not been adequately observed to ensure competency in performing nursing tasks, including verifying tube feeding orders and adhering to Enhanced Barrier Precautions. The facility's policy required that licensed nurses have the specific competencies necessary to care for residents' needs, but S2DON admitted that there was no process in place to track or evaluate nursing skills, and orientation training was primarily verbal without competency evaluations.
Failure to Use Appropriate PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff utilized appropriate personal protective equipment (PPE) during care for a resident requiring Enhanced Barrier Precautions. Specifically, during an observation, a registered nurse (S6RN) did not wear a gown while providing tube feeding to a resident with a percutaneous endoscopic gastrostomy (PEG) tube, despite the facility's policy requiring both gown and gloves for high-contact activities involving indwelling medical devices. The resident, identified as having a gastrostomy status, was admitted to the facility with orders for Enhanced Barrier Precautions due to the presence of the PEG tube. Interviews with the staff revealed a misunderstanding of the facility's policy on Enhanced Barrier Precautions. The registered nurse believed that only hand hygiene and gloves were necessary, while the facility's Infection Preventionist (S2DON) confirmed that the policy required both gown and gloves for care involving indwelling medical devices. This discrepancy in understanding and implementation of the policy led to the deficiency observed during the survey.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify the representative of a resident with severe cognitive impairment about a significant change in the resident's condition. The resident, who was admitted with diagnoses of cerebral infarction due to embolism and cardiomegaly, experienced vomiting and reported not feeling well on a specific date. Despite the facility's policy requiring prompt notification of a resident's representative in such cases, there was no documentation indicating that the representative was informed of the resident's condition change. Interviews with the staff involved revealed that the LPN assigned to the resident on the day of the incident could not recall notifying the resident's representative, and the CNA confirmed reporting the resident's condition to the LPN. The Director of Nursing also confirmed the lack of documentation regarding notification to the resident's representative or family. The resident's representative and family member both confirmed they were not informed of the change in condition, highlighting a deficiency in the facility's adherence to its notification policy.
Failure to Document Resident's Change in Condition and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by professional standards. Specifically, the nursing staff did not document a resident's change in condition, the notification of the provider about this change, or the administration of Zofran, a medication given to the resident. The facility's policy on documentation requires that all pertinent changes in a resident's condition, medication administration, and notifications to physicians be recorded. However, these actions were not documented for the resident in question. The resident, who had severe cognitive impairment and was admitted with diagnoses including cerebral infarction and cardiomegaly, experienced vomiting and a change in condition. Despite the nurse's verbal confirmation of notifying the nurse practitioner and administering Zofran, there was no written record of these actions in the resident's medical records. The Director of Nursing confirmed the lack of documentation and acknowledged that it should have been recorded according to the facility's policies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. The facility's policy required the use of gowns and gloves during high-contact resident care activities, such as urinary catheter care, to prevent the transmission of multidrug-resistant organisms. However, during an observation, a Licensed Practical Nurse (LPN) was seen performing urinary catheter care and a dressing change for a resident without wearing a gown, despite the posted EBP signage on the resident's door indicating the necessity of such precautions. The resident involved had been admitted with diagnoses of a urinary tract infection and retention of urine, and their clinical record confirmed the use of an indwelling catheter. The LPN admitted to being unclear about the requirement to wear a gown for catheter care, even after reviewing the EBP instructions. The Director of Nursing (DON) confirmed that the resident was on EBP and acknowledged that the LPN should have worn a gown during the care activities, indicating a lapse in adherence to the facility's infection control protocols.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their Minimum Data Set (MDS) documentation. For one resident with diagnoses including Schizophrenia and Paranoid Schizophrenia, the facility did not correctly code the resident's PASRR Level II status or serious mental illness on the most recent yearly MDS. This was confirmed through interviews with multiple staff members, including the MDS coordinators and the Director of Nursing (DON), who acknowledged the oversight and confirmed that the resident should have been coded correctly in their MDS assessments. Another resident, who had diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and was a fall risk, had a bed alarm in use as per physician orders and staff observations. However, the facility failed to accurately reflect the use of the bed alarm in the resident's annual and quarterly MDS assessments. Interviews with the resident's family member, Certified Nursing Assistants (CNAs), and Licensed Practical Nurse (LPN) confirmed the consistent use of the bed alarm to prevent falls. Despite this, the MDS assessments did not document the bed alarm usage, as directed by the corporate office, which instructed not to code the bed alarm under Section P as it was not considered a restraint. These inaccuracies in the MDS assessments indicate a failure to ensure that residents' assessments accurately reflected their status and needs. The facility's policies on MDS completion and conducting accurate resident assessments were not adhered to, resulting in incomplete and incorrect documentation of the residents' conditions and care requirements.
Failure to Maintain PASRR Documentation for Resident
Penalty
Summary
The facility failed to maintain a record of the Level 1 Preadmission Screening Resident Review (PASRR) form in the resident's medical record for one of the four residents reviewed. Resident #6, who was admitted with diagnoses including Unspecified Dementia with Mood Disturbance, Schizophrenia, Major Depressive Disorder, Anxiety Disorder, and Schizoaffective Disorder, did not have the required PASRR documentation in her clinical record. The absence of this documentation was confirmed during interviews with facility staff, who acknowledged that the preadmission packet received from the corporate outreach team did not include the Level 1 PASRR form. Interviews with the Social Worker (S10SW), Minimum Data Set Coordinator (S3MDS), and Director of Nursing (S2DON) revealed that the corporate outreach team and the discharging hospital were responsible for completing the Level 1 PASRR for non-local admissions. However, the facility did not verify the inclusion of the PASRR form in the preadmission packet for Resident #6. The staff confirmed that without the Level 1 PASRR form, there was no way to ensure that the resident was accurately screened prior to admission.
Failure to Provide Adequate Supervision for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as a fall risk. The resident, who had severe cognitive impairment and required assistance with toileting and transfers, experienced multiple falls. The facility's policy required staff to check on residents every 2 hours, but this was not adhered to for the resident in question. Video footage confirmed that staff did not enter the resident's room for extended periods, and interviews with staff corroborated that the required checks were not performed. The resident's clinical record indicated a history of falls and a care plan that included toileting every 2 hours to prevent falls. Despite this, the resident experienced numerous falls over several months. On a specific night, the assigned CNA admitted to not rounding on the resident every 2 hours due to being busy with other residents and failing to ask for assistance from other staff members. Interviews with various staff members, including the CNA, LPN, and DON, confirmed that the resident was a known fall risk and that the expectation was for staff to round every 2 hours. The facility's video footage further validated that the required checks were not conducted, leading to the deficiency in providing adequate supervision to prevent falls for the resident.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. Specifically, the facility did not ensure that a Certified Nursing Assistant (CNA) wore proper Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBPs). The CNA was observed performing incontinent care without wearing a gown, despite the resident being on EBPs due to having a peg tube and being at increased risk of multidrug-resistant organism (MDRO) acquisition. The deficiency was identified during an observation and interview process. The CNA confirmed that she did not wear a gown during the incontinent care of the resident, who was admitted with diagnoses including Congenital Stenosis and Stricture of Esophagus and was care planned for peg tube feeding. The Director of Nursing (DON) also confirmed that direct care staff should wear appropriate PPE, including a gown, when performing incontinent care on a resident with a peg tube. This failure to adhere to the facility's policy on EBPs was noted as a deficiency in the infection prevention and control program.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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