Maison De Lafayette
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Louisiana.
- Location
- 2707 Kaliste Saloom Road, Lafayette, Louisiana 70508
- CMS Provider Number
- 195365
- Inspections on file
- 30
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Maison De Lafayette during CMS and state inspections, most recent first.
Two residents with diagnoses requiring fluid management did not have daily weights obtained and documented as ordered by their physicians. Over several months, one resident missed 33 daily weights, and another had no weights recorded on two consecutive weekends. Staff interviews revealed unclear responsibility for weekend weight checks and a lack of daily verification by nursing leadership, resulting in unaddressed gaps in monitoring.
A resident was transferred to the hospital, and the facility did not provide the required written notice specifying the duration of the bed-hold policy to the resident or responsible party. Review of documentation and staff interviews confirmed that the notification was either not sent or did not include the necessary information about the bed-hold duration.
A resident with multiple neurological conditions and a pressure ulcer was receiving scheduled pain medication as ordered, but the MDS assessment was inaccurately coded to reflect that no scheduled pain medication was given. Staff confirmed the resident did receive pain medication and acknowledged the assessment error.
Staff did not conduct required two-hour rounding or provide timely peri-care for a dependent resident with dementia and incontinence, resulting in the resident being left soiled for several hours, as confirmed by family reports and video evidence.
A resident was hospitalized and readmitted on two occasions, but the facility did not complete and transmit a comprehensive MDS assessment within the required 14-day period after each readmission. The facility also did not provide a policy on MDS completion time frames when requested by surveyors, and an interview with the MDS nurse was not granted.
A resident with a history of falls, muscle weakness, and cognitive deficits experienced two falls within a short period. The care plan was not updated with individualized interventions after these incidents, and only standard measures such as keeping the bed low and call light within reach were documented, despite these already being in place.
The facility failed to maintain resident dignity by allowing a CNA to stand while feeding residents, contrary to policy, and by not providing a privacy cover for a resident's urinary catheter bag. The CNA admitted to standing for convenience, and the DON confirmed the policy violation. Additionally, the LPN acknowledged the lack of a privacy cover for the catheter bag.
The facility failed to follow recipes for pureed and chopped diets, as observed when dietary staff prepared meals with unmeasured ingredients and without using available recipes. This oversight could impact the nutritional intake and dining experience of residents on specialized diets.
The facility failed to support two residents' choices, impacting their self-determination. One resident, with intact cognition, experienced repeated neglect in removing food trays from their room, attracting pests. Another resident, also cognitively intact, was served meals containing items they disliked, despite clear documentation of these preferences. Staff confirmed awareness of these issues but did not act accordingly.
Two residents experienced deficiencies in their living environment. One resident's bathroom had scratched and peeling walls with holes in the sheetrock, which was not reported for maintenance until surveyors visited. Another resident's bathroom had a shower curtain with black spots and residue, which remained unclean over several days despite cleaning policies. The facility's staff acknowledged these issues, indicating a failure to maintain a homelike environment.
The facility failed to update PASARR screenings for two residents with newly identified mental disorders. One resident had new psychiatric diagnoses not included in their existing screening from 2006, and another resident was diagnosed with mental illnesses in 2023 without a new screening being conducted. The Social Services Directors confirmed the absence of updated screenings.
A resident with multiple diagnoses, including End Stage Renal Disease and Tobacco Use, was found with cigarettes despite being assessed as an unsafe smoker requiring supervision. The care plan required the care team to store the resident's smoking materials, but this was not followed. Additionally, the facility failed to remove the resident's dialysis dressing as per physician's orders, leaving an old dressing with blood on the site. These actions indicate non-compliance with the care plan and physician's directives.
The facility failed to update care plans for two residents. One resident refused to wear an abdominal binder due to pain, but this was not documented, and the LPN did not inform the physician. Another resident's care plan was not updated to reflect a change from Full Code to DNR, as the MDS coordinators were unaware of the change.
A resident with a urinary catheter was observed with the catheter bag improperly positioned above the bladder on the arm of a wheelchair, rather than below the bladder as required. The resident, who had a history of refusing catheter care but had not refused in recent months, was confirmed by an LPN to have the catheter bag incorrectly placed.
A resident with a PEG tube for enteral feeding did not receive appropriate care as the facility failed to change the dressing daily as ordered. The dressing was found unchanged for three days, confirmed by an LPN and the ADON, despite physician's orders for daily cleansing and dressing application.
A resident with moderate cognitive impairment was found with eye drops at her bedside, which she sometimes self-administered without a formal assessment for self-administration. The facility's policy requires such an assessment, but it was not conducted, leading to improper medication storage.
Two residents did not receive timely and adequate meals due to the facility's failure to provide breakfast before their doctor's appointments. One resident, with multiple health conditions, missed breakfast due to a lack of plates and eggs, while another resident, with pulmonary and vascular issues, experienced frequent delays and cold meals. Both residents left for their appointments without eating, highlighting a deficiency in meal service.
The facility failed to provide timely meal delivery for 57 residents due to insufficient dietary staff in Kitchen 3. Meals were consistently delivered late, with breakfast and lunch trays observed being served past scheduled times. The Dietary Manager noted issues such as poor phone reception and the need for staff to walk to another kitchen for supplies, contributing to the delays.
A housekeeping staff member failed to notify nursing staff when a resident was heard yelling for help. Despite hearing the cries, the staff member continued with her duties without investigating or alerting the nursing team. The housekeeping supervisor confirmed that staff are expected to use the resident's call button or notify the supervisor if they hear a resident in distress. The facility administrator expressed disbelief at the staff member's inaction.
A facility failed to protect a resident's confidential information by not enabling a computer's privacy screen during a treatment for another resident. An unattended treatment cart with a visible computer screen displayed private medical information. The ADON confirmed that computer screens should be locked when unattended, and the LPN admitted to not locking the screen, thus breaching confidentiality policies.
A resident with a history of Traumatic Subdural Hemorrhage, Major Depressive Disorder, and Dementia was placed on a concave mattress to prevent falls, effectively restraining them without proper assessment or physician's orders. Staff did not consider the mattress a restraint, leading to a failure to conduct a necessary evaluation.
Failure to Obtain and Document Daily Weights for Residents with Fluid Management Needs
Penalty
Summary
The facility failed to follow physician orders to obtain and document daily weights for two residents with diagnoses including congestive heart failure and fluid overload. For one resident, there were 33 instances over several months where daily weights were not recorded, despite clear physician orders and care plan interventions specifying the need for daily monitoring. The resident's responsible party reported that the facility provided various excuses for not obtaining weights, such as malfunctioning equipment or inability to locate the scale, and that the facility did not implement the physician's orders in a timely manner. There was no documentation indicating that the resident refused to be weighed on the missed days. Staff interviews revealed that the CNA/Weight Tech was responsible for obtaining weights Monday through Friday, while floor CNAs were expected to obtain weights on weekends. However, the process for ensuring weights were obtained on weekends was not effectively managed, and nurses were identified as ultimately responsible for ensuring compliance with orders. The Assistant Director of Nursing (ADON) generated weekly weight reports but did not verify daily compliance by reviewing each resident's chart, resulting in unawareness of the missed weights. The Director of Nursing (DON) and ADON both confirmed that staff should have identified and addressed the missed weights, and that the resident could have been weighed even if in a chair using a Hoyer lift. A second resident with orders for daily weights also had undocumented weights on two consecutive weekends. The ADON confirmed that daily weights were ordered and acknowledged that staff did not identify the missed documentation. Both residents had medical conditions requiring close monitoring of fluid status, and the failure to obtain and document daily weights as ordered was confirmed through record review and staff interviews.
Failure to Provide Written Bed-Hold Duration Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a resident or their responsible party with written notice specifying the duration of the bed-hold policy at the time of transfer to the hospital. Review of the facility's policy indicated that the business office is responsible for informing residents or their representatives about readmission appeal rights and bed-hold policies. However, examination of the Emergency Transfer Log for the relevant period showed that the section for written notification to the resident was left blank for the resident who was transferred and later returned. Interviews with the Social Services Director revealed a lack of awareness regarding the requirement to send written notification about the bed-hold duration or payment policy at the time of transfer. Additionally, review of the Bed Hold Agreement provided by the Administrative Assistant confirmed that it did not include information explaining the duration of the bed-hold.
Inaccurate MDS Assessment for Pain Medication Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. A resident with a history of metabolic encephalopathy, cerebral infarction, memory deficit, and hemiplegia was admitted to the facility and had a physician's order for scheduled Tylenol for pain management. During an interview, the resident reported experiencing pain from a pressure ulcer and confirmed receiving pain medication, which was supported by physician orders. However, review of the resident's quarterly MDS assessment showed that it was incorrectly coded to indicate that the resident did not receive any scheduled pain medications during the look-back period. Staff responsible for completing the MDS assessment confirmed during interviews that the resident did receive pain medication and acknowledged the error in coding.
Failure to Provide Timely ADL Care and Rounding for Dependent Resident
Penalty
Summary
Facility staff failed to provide required Activities of Daily Living (ADL) care for a dependent resident who was unable to perform self-care. The resident, who had diagnoses including unspecified dementia and urinary tract infection, was always incontinent of bowel and bladder and required substantial or maximal assistance for toileting. Medical record review and interviews revealed that certified nursing assistants (CNAs) were expected to round every two hours to ensure residents were clean, provided with peri-care, and had their needs met. However, video evidence from the resident's electronic monitoring device showed that staff did not perform peri-care or rounds at the required intervals, resulting in the resident being left soiled for several hours. The deficiency was further substantiated by interviews with the resident's family member, who reported that the resident was not being rounded on every two hours and was left soiled for extended periods. The facility administrator confirmed that staff were instructed to round every two hours but could not provide video evidence to support that this was done for the resident in question. The failure to conduct timely rounds and provide necessary ADL care was observed for one resident out of three sampled, as documented by both family reports and video footage.
Failure to Complete Timely Comprehensive MDS Assessment After Readmission
Penalty
Summary
The facility failed to complete and transmit a comprehensive Minimum Data Set (MDS) assessment within the required 14-day timeframe following a resident's readmission after hospitalization. Record review showed that one resident was hospitalized and subsequently readmitted on two separate occasions, but the electronic clinical record did not contain evidence that a comprehensive MDS assessment was completed and transmitted within 14 days after each readmission. Additionally, when surveyors requested the facility's policy on MDS completion and submission time frames, no policy was provided by the time of survey exit. An interview with the MDS nurse could not be conducted as requested by surveyors, as the Regional Administrator required questions to be submitted in writing.
Failure to Develop Resident-Specific Care Plan After Multiple Falls
Penalty
Summary
The facility failed to develop and implement a complete, resident-specific care plan following two documented falls for one resident. The resident, who had a history of falls, muscle weakness, abnormal gait, cognitive deficits, dementia, and a prior femur fracture, experienced two falls within a five-day period. Nursing progress notes detailed that the resident was found on the floor on both occasions, once next to the bed and once partially under the bed, with the second incident involving incontinence and an attempt to use the bathroom independently. Review of the resident's care plan revealed that interventions such as keeping the call bell and assistive devices within reach and toileting before bed were already in place. After the second fall, the only update to the care plan was to keep the bed in the lowest position and the call light within reach, which staff acknowledged were standard interventions and not specific to the resident's needs. The quality nurse confirmed that no new, individualized interventions were added to address the resident's repeated falls.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal assistance and in the management of a urinary catheter. Observations revealed that a Certified Nursing Assistant (CNA) was standing while feeding three residents, which is against the facility's policy that requires staff to sit while assisting residents with meals to ensure their dignity. The CNA admitted to standing because it was easier for her, acknowledging that she should have been sitting. The Director of Nursing confirmed that staff should not stand over residents during meal assistance. Additionally, the facility did not maintain the dignity of a resident with a urinary catheter by failing to provide a privacy bag or covering for the urine collection bag. Observations showed the catheter drainage bag was visible and not covered while the resident was in bed and in a wheelchair, exposing the contents to others. A Licensed Practical Nurse confirmed that the catheter drainage bag should have had a privacy covering, which it did not.
Failure to Follow Recipes for Pureed and Chopped Diets
Penalty
Summary
The facility failed to ensure that recipes for pureed and chopped diets were followed, which could potentially affect the nutritional intake and dining experience of residents. During an observation, the Dietary Supervisor was seen preparing a pureed dessert without using a recipe, adding unmeasured amounts of ingredients such as chocolate peanut butter bars and milk. Similarly, a cook was observed preparing pureed black-eyed peas and rice without using recipes, adding unmeasured amounts of milk and thickener, and failing to measure the portions served to residents. The Dietary Manager confirmed that recipes were available in the kitchen and should have been used by the staff. The cook, who was filling in, was unaware of the recipes and did not use them while preparing meals for residents on pureed diets. This lack of adherence to recipes and portion control could lead to inadequate nutritional intake for the residents who rely on these specialized diets.
Failure to Support Resident Choices in Meal Preferences and Room Cleanliness
Penalty
Summary
The facility failed to promote and facilitate residents' self-determination by not supporting their choices regarding significant aspects of their lives. For Resident #25, the facility did not remove completed food trays from the resident's room, despite the resident's expressed dislike for this practice due to concerns about attracting roaches. The resident, who has intact cognition as indicated by a BIMS score of 15, reported that this issue occurred frequently. A CNA confirmed that she was responsible for picking up the trays on the specified date but failed to do so. For Resident #35, the facility did not adhere to the resident's documented food preferences. Despite having a BIMS score of 15, indicating intact cognition, and clear documentation of food dislikes such as oatmeal and bacon, these items were repeatedly served to the resident. Observations confirmed that the resident received meals containing these disliked items, and the Assistant Director of Nursing acknowledged that the meal tickets clearly indicated these preferences, which were not followed.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident #1's bathroom was found to be in disrepair, with scratched and peeling walls and four holes in the sheetrock. The Assistant Director of Nursing confirmed the condition and stated that maintenance was responsible for repairs. The Maintenance Supervisor revealed that he was only made aware of the issue when surveyors were present, despite the facility's policy of conducting Ambassador Rounds to report such issues. The Director of Nursing, who was responsible for Resident #1's room, admitted to not reporting the maintenance needs until the surveyors' visit. Resident #123's bathroom was also found to be lacking in cleanliness, with a shower curtain covered in black spots and residue. Despite the facility's policy requiring regular cleaning and disinfection, the shower curtain remained unclean over multiple days. The Housekeeping Supervisor confirmed the condition of the shower curtain and acknowledged that the housekeeping staff was responsible for its maintenance. These observations indicate a failure in maintaining a clean and homelike environment for the residents.
Failure to Update PASARR Screenings for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with newly identified mental disorders to the appropriate state-designated authority for review, as required by the Pre Admission Screening and Resident Review (PASARR) program. For Resident #16, the facility did not update the Level I PASARR screening upon admission in 2021, despite the resident having new psychiatric diagnoses of Unspecified Psychosis and Psychotic Disorder with Hallucinations. The only Level I screening available was from 2006, completed at another facility, which did not include these diagnoses. The Social Services Director confirmed the absence of an updated screening. Similarly, for Resident #125, the facility did not conduct a new Level I PASARR screening after the resident was diagnosed with mental illnesses, including Dementia without Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder in 2023. The existing Level I screening from 2022 did not reflect these diagnoses. Interviews with the Social Services Directors confirmed that no new screening was submitted to the appropriate agency following the new diagnoses.
Failure to Follow Care Plan for Resident's Smoking and Dialysis Dressing
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as Resident #72, by not ensuring that the resident did not have cigarettes in her possession and by not following the physician's orders regarding the removal of the resident's dialysis dressing. The resident, who was admitted with diagnoses including Encephalopathy, End Stage Renal Disease, Anxiety Disorder, Altered Mental Status, and Tobacco Use, was observed holding a pack of cigarettes on her lap while wheeling herself down the hall. Despite being assessed as an unsafe smoker requiring supervision, the resident was found with cigarettes, contrary to the care plan intervention that required the care team to store her smoking materials. The Director of Nursing confirmed that the resident should not have had cigarettes in her possession. Additionally, the facility did not follow the physician's orders to remove the resident's dialysis dressing on specified days. An observation on June 12 revealed that the resident had an old dressing on her left arm covering the dialysis cannulation site, with old blood noted on the dressing. The LPN confirmed that the dressing should have been removed earlier in the week, as per the physician's orders. These failures indicate a lack of adherence to the established care plan and physician's directives for the resident.
Care Plan Revisions Not Updated for Two Residents
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in their care. Resident #25, who was admitted with a ventral hernia, had a physician's order for an abdominal binder to be worn during the day for support. Despite this order, the resident consistently refused to wear the binder due to increased pain, which was not documented in the care plan. Observations and interviews confirmed that the resident was not wearing the binder on multiple occasions, and the LPN admitted to not applying it and failing to inform the physician of the resident's refusal. Resident #89's care plan was not updated to reflect a change in their code status from Full Code to DNR, as indicated by a physician's order and the resident's Lapost. The MDS coordinators responsible for updating the care plan were unaware of the change in code status, resulting in the care plan inaccurately stating the resident was Full Code. This oversight was identified during a review of the facility's policy on Advanced Directives, which requires the care plan to align with the resident's documented treatment preferences.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with diagnoses including Bladder Disorder and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, had an intact cognitive status as indicated by a BIMS score of 15. Observations on the morning of June 10, 2024, revealed that the resident's urinary catheter bag was improperly positioned on the arm of his wheelchair, above the level of his bladder, rather than below it as required. An LPN confirmed the incorrect positioning during an interview and observation, acknowledging that the catheter bag should have been placed below the bladder. The resident had a history of refusing catheter care, but had not refused care in the past couple of months.
Failure to Change PEG Tube Dressing as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a PEG tube. The resident, who was admitted with diagnoses including malignant neoplasm of overlapping sites of the oropharynx and carcinoma in situ of the skin of the right upper limb, was receiving 26-50% of his nutrition through tube feeding. According to the physician's orders, the PEG site was to be cleansed with soap and water, patted dry, and a split gauze dressing applied daily. However, during an observation and interview, it was found that the dressing on the resident's PEG tube site had not been changed for three days, as it was dated three days prior. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the dressing had not been changed as required by the physician's orders. Both staff members acknowledged that the dressing should have been changed daily, as per the orders, but it had not been done, leading to a lapse in the care provided to the resident. This oversight in following the prescribed care regimen for the PEG tube site represents a deficiency in the facility's adherence to medical orders and protocols for enteral feeding care.
Improper Medication Storage and Self-Administration
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by eye drops being left at the bedside of a resident. The resident, who was admitted with diagnoses including preglaucoma and occipital neuralgia, had a BIMS score indicating moderate cognitive impairment. Despite this, the resident was found to have eye drops on her dresser and at her bedside, which she sometimes administered herself without a formal assessment for self-administration by the interdisciplinary care planning team. The facility's medication administration policy requires that residents may only self-administer medications if deemed safe by the attending physician and care planning team. However, the resident had not been assessed for this capability. An LPN confirmed that the eye drops should not have been left at the bedside, indicating a lapse in adherence to the facility's medication storage and administration policies.
Failure to Provide Timely and Adequate Meals
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet to meet the nutritional needs of two residents. Resident #51, who has multiple diagnoses including Acute Kidney Failure and Celiac Disease, did not receive breakfast on the morning of 06/10/2024 before leaving for a doctor's appointment. The resident reported that the kitchen was out of plates and eggs, and a CNA confirmed that the resident did not receive her breakfast tray before her appointment. The resident left for her appointment without eating and did not have a meal until lunch upon her return. Resident #92, diagnosed with Interstitial Pulmonary Disease and Peripheral Vascular Disease, was also affected by the facility's failure to provide timely meals. On the same morning, the resident was scheduled for a doctor's appointment and did not receive breakfast because it was late. Both the resident and a family member reported that meals were frequently late and cold. An LPN confirmed that breakfast should have been served by 8:00 a.m., and any delay beyond that time was considered late. As a result, the resident left for her appointment without having breakfast.
Delayed Meal Service Due to Insufficient Dietary Staff
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal delivery for 57 residents consuming meals from Kitchen 3. According to the facility's policy, residents should receive meals at scheduled times, with breakfast at 7:30 a.m. and lunch at 11:30 a.m. However, interviews and observations revealed that breakfast and lunch trays were consistently delivered late to residents on Hall A. For instance, a resident reported not receiving breakfast until almost 9:00 a.m., and another resident confirmed that breakfast was often late. Observations on June 10 and June 11 showed that the last breakfast and lunch trays were delivered significantly past the scheduled times. The Dietary Manager (S11DM) acknowledged that Kitchen 3 faced challenges, including poor phone reception and the need for staff to walk to Kitchen 1 for additional supplies, which contributed to delays. The Dietary Supervisor (S23DS) confirmed that all food was prepared in Kitchen 1, with Kitchens 2 and 3 used for distribution. The lack of coordination and communication between the kitchens and the CNAs responsible for distributing meal trays further exacerbated the issue, leading to the deficiency in timely meal service.
Failure to Notify Nursing Staff of Resident's Distress
Penalty
Summary
The facility failed to ensure that environmental staff possessed the necessary qualifications or competencies, as evidenced by an incident involving a housekeeping staff member, S9Hsk, who did not notify nursing staff when a resident was heard yelling for help. During a random observation, a surveyor noted that Resident #93 was yelling for help from behind a closed door. Despite hearing the resident's cries, S9Hsk continued with her duties without investigating or notifying the nursing staff. This incident occurred shortly after S9Hsk was hired, and she confirmed that she had completed onboarding training, which included instructions to report any changes in a resident's behavior to the nursing staff. The housekeeping supervisor, S8HskSup, confirmed that the expectation for housekeeping staff is to use the resident's call button to alert the nursing staff and wait with the resident until help arrives. Alternatively, they should notify the supervisor by cell phone if they cannot reach the call button. However, S9Hsk did not follow these procedures and failed to notify anyone about the resident's distress. The facility administrator expressed disbelief that S9Hsk did not interpret the resident's screaming as a sign of distress, indicating a gap in the staff's understanding of their responsibilities in such situations.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to protect confidential information for a resident by not enabling the computer's privacy screen during a treatment being administered to another resident. This incident was observed when a treatment cart was left unattended outside a resident's room with the computer screen visible, displaying private medical information about another resident. The facility's policy on confidentiality and personal privacy, which was last reviewed in January 2024, mandates that personal and medical records be safeguarded and access limited to authorized staff. During interviews, the Assistant Director of Nursing confirmed that the expectation for treatment carts is the same as for medication carts, requiring computer screens to be locked when unattended. The Treatment LPN, responsible for documenting on the computer present on the treatment cart, acknowledged that the privacy screen should be locked when the cart is left unattended. She admitted to not locking the computer screen when she left the cart in the hallway to provide care to a resident, thus failing to protect the confidentiality of resident information.
Failure to Ensure Resident is Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical restraints. The resident, who had a history of Traumatic Subdural Hemorrhage, Major Depressive Disorder, and Dementia, was placed on a concave mattress as a fall prevention measure. However, there was no physician's order or assessment for the use of this mattress, which effectively restrained the resident by preventing them from getting out of bed without assistance. Interviews with various staff members, including the Hospice Nurse, Assistant Director of Nursing, Director of Nursing, and a Licensed Practical Nurse, revealed that the concave mattress was used to prevent the resident from rolling out of bed, but none of them considered it a restraint, and therefore, no restraint assessment was completed. The facility's policy on the use of restraints states that restraints should only be used to treat a resident's medical symptom and never for discipline, staff convenience, or fall prevention. Despite this policy, the concave mattress was used without proper assessment or physician's orders, effectively restraining the resident. The staff's misunderstanding of what constitutes a restraint led to the failure to conduct a necessary evaluation, resulting in the resident being subjected to an unnecessary physical restraint.
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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