Metairie Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metairie, Louisiana.
- Location
- 6401 Riverside Drive, Metairie, Louisiana 70003
- CMS Provider Number
- 195278
- Inspections on file
- 22
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Metairie Health Care Center during CMS and state inspections, most recent first.
A review of personnel records and staff interviews revealed that several CNAs did not receive effective communication training since their hire. The CNA supervisor confirmed that such training was not part of orientation or in-service programs, and the DON verified the lack of training for these staff members.
Mandatory QAPI training was not provided to direct care staff, as confirmed by personnel records and staff interviews. Five CNAs had no documentation of receiving QAPI training since hire, and both the CNA Supervisor and DON acknowledged that this training was not included in orientation or in-service sessions.
The facility did not include direct care staff, a resident, or a resident representative in the development of its facility-wide assessment. Documentation and interviews confirmed that an RN, LPN, CNA, a resident, and a resident representative were not involved in the assessment process.
An LPN did not wear gloves or perform hand hygiene as required during PEG tube dressing changes for a resident on Enhanced Barrier Precautions. The LPN handled the dressing and performed site care without proper PPE and failed to wash hands at key points, despite clear facility policies and signage. The DON confirmed these lapses in infection control practices.
The facility did not include the daily census in the posted nurse staffing information at the start of a shift, as required. This was confirmed by both a CNA Supervisor and the Administrator, who was unaware of the requirement.
An LPN left a computer unattended in a hallway with a resident's private medical information visible on the screen while administering medication. Both the LPN and the DON confirmed that the screen should have been locked to protect the resident's confidentiality, and acknowledged this was a HIPAA violation.
Two residents and their representatives were not provided with a summary of the Baseline Care Plan within 48 hours of admission. Although the Baseline Care Plans were completed, there was no documentation or signatures to confirm that the summaries were given, and both residents and the DON confirmed in interviews that the required information was not provided.
Two residents did not have their comprehensive care plans prepared by a full interdisciplinary team, as required. In both cases, only the social worker, MDS coordinator, and in one instance, the rehab director or a resident representative, participated. There was no documentation that the residents, their representatives, or other required IDT members, such as the attending physician, were involved or invited. Staff confirmed that physicians and other designated providers did not participate in care plan preparation.
The facility failed to supervise residents identified as unsafe smokers, leading to multiple instances where residents were found with smoking materials and without required safety devices. A resident with moderate cognitive impairment was observed smoking unsupervised, without a smoking apron, and in possession of a lighter and cigarettes. Staff interviews revealed a lack of awareness and enforcement of safety measures for these residents.
The facility failed to implement its smoking policy effectively, resulting in an Immediate Jeopardy situation when a resident identified as an unsafe smoker was found smoking alone, unsupervised, and in possession of smoking materials. The staff had not been educated on the smoking policy, and the administrator acknowledged responsibility for ensuring smoker safety and policy adherence.
A facility failed to report a resident-to-resident physical abuse incident to the Statewide Incident Management System within the required timeframe. The incident involved a resident entering another resident's room and physically assaulting her. Despite internal reporting to the DON and Administrator, there was no evidence of the incident being reported to the SIMS as required by policy.
A facility failed to investigate an abuse allegation and provide increased supervision after a resident reported being punched by another resident. Despite policy requirements, there was no evidence of a thorough investigation or immediate increased supervision. Visual checks for the involved resident began days later, but no immediate action was taken. Interviews confirmed the lack of documentation and acknowledgment of the oversight.
The facility failed to ensure staff competency in managing unsafe smoking behaviors for three residents identified as unsafe smokers. Observations revealed a resident with impaired cognition was unsupervised with smoking materials, contrary to policy requirements. Interviews indicated staff were unaware of the smoking policy and specific interventions needed for these residents. The administrator confirmed the lack of staff training and policy enforcement.
A facility failed to administer a pneumonia vaccine to a resident despite having obtained consent from the resident's Responsible Party. The medical record showed that consent was signed, but there was no documentation of the vaccine being administered. The DON confirmed the vaccine was not given.
A resident with severe cognitive impairment entered another resident's room and physically assaulted her while she was asleep, despite the facility's zero-tolerance policy for abuse. The incident was reported to the ADON and DON shortly after it occurred, highlighting a failure in protective measures.
A facility failed to properly label an enteral feeding bag for a resident with dysphagia and gastrostomy status. Observations revealed that the feeding and flush bags lacked necessary information such as the resident's name, date and time of initiation, and infusion rate. Staff interviews confirmed the oversight, acknowledging that the bags should have been labeled according to facility policy.
The facility failed to maintain accurate records of controlled drugs for two medication carts, as required by their policy. Missing signatures were found on the controlled drugs-count records for several shifts, indicating a lapse in adherence to the facility's procedures. Staff interviews confirmed these discrepancies, highlighting a failure to ensure the accuracy and security of controlled substances.
A facility failed to monitor a resident's drug regimen for unnecessary medications, specifically Prozac and Buspirone, prescribed for major depressive disorder and anxiety. There was no documented evidence of side-effect or behavior monitoring on several occasions in December 2024. Interviews with the ADON and DON confirmed the lack of documentation, indicating a failure to ensure proper monitoring of the resident's condition and response to medications.
A resident's urinalysis, ordered to investigate aggressive behavior, was delayed by five days, and treatment for a UTI was not initiated until three days after results were available. The DON acknowledged the sample should have been collected and treatment started sooner.
A resident with moderate cognitive impairment reported dissatisfaction with the taste of meals at the facility. Surveyors observed that an alternate meal was not palatable, with lukewarm mashed potatoes and gravy, a thin cod fish patty mostly consisting of breading, and mushy steamed broccoli. The Dietary Manager acknowledged the issues with the meal's palatability and temperature.
The facility failed to label opened food products with dates and maintain kitchen equipment in a sanitary condition. Eight food items were found without open dates, and there was grease buildup on kitchen equipment. The Dietary Manager acknowledged these issues, which are against the facility's policies.
The facility failed to ensure proper hand hygiene between assisting two residents with meals and did not maintain proper handling of a urinary catheter for a resident, as the tubing and collection bag were observed on the floor. These deficiencies were confirmed by staff and violated the facility's infection prevention policies.
The facility failed to adhere to its employment screening policies by hiring a CNA with a charge of aggravated assault with a firearm, a disqualifying offense under state regulations. The facility's policy required pre-employment screenings and barred employment for individuals with certain felony convictions. Despite this, the CNA was hired without documented evidence of a charge disposition, as confirmed by the DON.
A medication room was left unlocked and unattended for over an hour, with a door stop keeping it open. The ADON placed the door stop and left the room, which contained medications, unsecured. The DON and Administrator confirmed the deficiency.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide effective communication training to direct care staff, as evidenced by personnel record reviews and staff interviews. Five certified nursing assistants (CNAs) with varying hire dates, ranging from 2011 to 2025, did not receive any effective communication training since their employment began. The CNA supervisor, responsible for new hire orientation, confirmed that effective communication training was not included in orientation or in-service training. The Director of Nursing also confirmed that these CNAs had not received the required training. These findings were based on interviews and record reviews, with no evidence of effective communication training documented for the sampled staff.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all direct care staff, as evidenced by record reviews and staff interviews. Personnel records for five Certified Nursing Assistants (CNAs) with varying hire dates showed no documentation of QAPI training since their employment began. The CNA Supervisor, responsible for new hire orientation, confirmed that QAPI training was not included in orientation or in-service education. The Director of Nursing also verified that these staff members had not received QAPI training.
Lack of Involvement in Facility Assessment Development
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included active involvement from direct care staff, residents, and residents' representatives in its development. Review of the facility assessment revealed that a resident, a resident representative, and direct care staff—including an RN, LPN, and CNA—were not included in the assessment process. During an interview, the administrator confirmed there was no documentation showing participation from these individuals in the development of the assessment.
Failure to Follow PPE and Hand Hygiene Protocols During PEG Tube Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube who was on Enhanced Barrier Precautions (EBP). Facility policy required staff to wear gloves during high-contact care activities for residents with indwelling medical devices and to perform hand hygiene before and after direct resident contact, handling invasive devices, and after removing gloves. Despite these requirements, an LPN entered the resident's room without gloves, removed the PEG tube dressing with bare hands, and only applied gloves after this step without performing hand hygiene. The LPN then cleaned the PEG tube site, removed gloves, and redressed the site with ungloved hands, again failing to perform hand hygiene. The EBP signage on the resident's door clearly indicated that gloves were required for feeding tube care. Both the LPN and the Director of Nursing confirmed that proper glove use and hand hygiene were not followed during the procedure. The resident involved had an active order for PEG tube site care and was on EBP with specific interventions for staff to wear gloves.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information at the beginning of each shift, as mandated. On one of the two days observed, the posted nurse staffing information did not include the facility's daily census. This omission was confirmed during an observation and through interviews with the CNA Supervisor and the Administrator, both of whom acknowledged that the daily census should have been included in the posted information. The Administrator also indicated he was unaware of this requirement.
Resident Medical Information Left Visible on Unattended Computer
Penalty
Summary
During a medication pass, a Licensed Practical Nurse (LPN) left a computer unattended in the hallway with the screen visibly displaying a resident's private medical information. This occurred when the LPN stepped away from the computer to administer medication in the resident's room. The facility's policy, which aligns with federal and state laws, requires the privacy and confidentiality of all residents' medical records to be maintained. Both the LPN and the Director of Nursing (DON) confirmed that the computer screen should have been locked to prevent unauthorized access to the resident's information, and acknowledged that leaving the screen unattended constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA).
Failure to Provide Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a Baseline Care Plan summary to two residents and their representatives within 48 hours of admission, as required. For one resident with severe cognitive impairment, the Baseline Care Plan was completed on the day of admission, but there was no documentation that the summary was provided to either the resident or their representative. The signature and date boxes for both the resident and representative were left unsigned and undated, and the facility could not produce any evidence that the summary had been given. The resident's representative confirmed in a telephone interview that they had not received the Baseline Care Plan summary. Similarly, for another resident who was cognitively intact, the Baseline Care Plan was completed on the admission date, but again, there was no documentation that the summary was provided to the resident or their representative. The required signature and date boxes were not completed, and both the resident and the DON confirmed in interviews that the summary had not been provided. The facility was unable to present any documentation to show that the Baseline Care Plan summaries were given to either resident or their representatives.
Failure to Include Required Interdisciplinary Team Members in Care Plan Preparation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were prepared by a complete interdisciplinary team (IDT) for two of three residents reviewed. For one resident with severe cognitive impairment, the care plan meeting was attended only by the social worker, MDS coordinator, and rehab director, with no documented evidence that the resident, their representative, or other required IDT members participated or were invited. The resident's representative confirmed not being given the opportunity to attend or participate in the care plan preparation. For another resident who was cognitively intact, the care plan meeting included only the social worker, MDS coordinator, and the resident's representative, with no documentation that the resident or other required IDT members were involved or invited. The resident stated she was not given the opportunity to participate in her care plan preparation. Multiple staff interviews confirmed that attending physicians and other designated providers did not participate in the preparation of individual comprehensive care plans, and there was no documentation to show their involvement.
Failure to Supervise Unsafe Smokers
Penalty
Summary
The facility failed to ensure that residents with a history of unsafe smoking were using safety smoking devices and were supervised while smoking. This deficiency was observed in three residents who were identified as unsafe smokers. Resident #31, who had moderate cognitive impairment, was observed smoking without a smoking apron and without staff supervision, despite his care plan requiring these safety measures. The facility's policy required that unsafe smokers not have smoking paraphernalia in their possession and be supervised while smoking, but this was not enforced. Resident #31 was observed multiple times with burn holes in his shirt and in possession of a lighter and cigarettes, indicating a lack of supervision and adherence to his care plan. Interviews with staff revealed a lack of awareness regarding Resident #31's status as an unsafe smoker and the necessary precautions. Similarly, Resident #15 was found with cigarettes in his possession, contrary to his care plan, which required supervision and the use of a smoker's apron. Staff interviews indicated a lack of awareness of Resident #15's unsafe smoking status. Resident #53, who was cognitively intact, was also identified as an unsafe smoker requiring supervision and a smoker's apron. However, he was found with smoking materials in his possession, and staff interviews confirmed that he should not have had these items. The facility failed to maintain a list of unsafe smokers at the nurses' station, and administrative staff were aware of the lack of supervision and enforcement of safety measures for these residents.
Failure to Implement Smoking Policy Leads to Immediate Jeopardy
Penalty
Summary
The administrative staff at the facility failed to effectively implement the smoking policy and procedures for monitoring and supervision, leading to a deficiency in ensuring the safety of residents identified as unsafe smokers. Specifically, Resident #31, who was on the unsafe smoker list, was observed smoking alone on the smoking patio, in possession of a cigarette and a lighter, and without wearing a smoker's apron or being supervised. This incident occurred despite the facility's policy requiring that residents who continue to smoke be assessed for safety and that designated smoking areas be enforced by the administrator. Interviews revealed that the facility's staff had not been educated on the smoking policy prior to the incident. The S1Administrator acknowledged responsibility for ensuring the safety of smokers and adherence to the facility's smoking policy. The lack of oversight and failure to implement the smoking policy resulted in an Immediate Jeopardy situation, as it posed a likelihood of more than minimal harm to the residents identified as unsafe smokers.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the Statewide Incident Management System (SIMS) within the required two-hour timeframe. The incident involved Resident #62 entering Resident #5's room and physically assaulting her by punching her in the face while she was asleep. This incident was documented in Resident #5's progress notes and an undated Resident Incident Report, which indicated that Resident #62 had propelled his wheelchair into Resident #5's room and assaulted her. Despite the incident being reported internally to the Director of Nursing (DON) and subsequently to the Administrator, there was no documented evidence that the incident was reported to the SIMS as required by the facility's policy. The Administrator, who was the only staff member authorized to input incidents into the SIMS, failed to provide evidence of such a report being made. This lack of timely reporting constitutes a deficiency in the facility's adherence to its abuse, neglect, and misappropriation of funds program policy.
Failure to Investigate and Supervise After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving two residents. Resident #5 reported being punched in the face by Resident #62 while asleep. Despite the facility's policy requiring immediate investigation and documentation of such incidents, there was no evidence that the Director of Nursing or Administrator conducted a thorough investigation on the date of the incident. The facility's Resident Incident Report lacked documentation indicating whether the allegation was found to be valid or invalid, and there was no 24-hour follow-up recorded. Additionally, the facility did not provide increased supervision for Resident #62 after the incident, as required by their policy in cases of resident-to-resident abuse. Although visual checks for Resident #62 were documented starting several days after the incident, there was no immediate action taken to monitor or separate the involved resident. Interviews with the Director of Nursing and the Administrator confirmed the absence of documented evidence for both the investigation and the increased supervision, acknowledging that these steps should have been completed.
Failure to Ensure Staff Competency in Managing Unsafe Smoking
Penalty
Summary
The facility failed to ensure that staff demonstrated competency in assessing and managing unsafe smoking behaviors for three residents identified as unsafe smokers. The facility's policy required that residents identified as unsafe smokers should not have smoking paraphernalia in their possession and should be supervised while smoking. However, observations revealed that Resident #31, who had moderately impaired cognition and was identified as an unsafe smoker, was found unsupervised with smoking materials and without a required smoker's apron on multiple occasions. Additionally, there was no documented evidence of a list of unsafe smokers at the nurses' station. Interviews with staff members, including the Director of Nursing and Certified Nursing Assistants, indicated a lack of training and awareness regarding the facility's smoking policy and the specific needs of residents identified as unsafe smokers. Staff members were unaware of the interventions required for these residents, such as the need for supervision and the use of a smoker's apron. This lack of training and awareness contributed to the failure to enforce the facility's smoking policy effectively. The facility's administrator confirmed that the responsibility for ensuring staff education and training on the unsafe smoking policy was not fulfilled. The administrator acknowledged that staff training and education were not implemented, and the policy was not enforced as required. This deficiency in staff competency and policy enforcement led to residents being unsafely exposed to smoking materials, contrary to the facility's established procedures.
Failure to Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that a pneumonia vaccine was administered to a resident, despite having obtained consent from the resident's Responsible Party (RP). The medical record of the resident indicated that the RP signed a consent form on January 10, 2024, authorizing the administration of the pneumonia vaccine. However, there was no documented evidence that the vaccine was administered as per the consent. During an interview on December 17, 2024, the Director of Nursing (DON) confirmed that the pneumonia vaccine had not been administered to the resident after the consent was signed.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from resident-to-resident physical abuse. The incident involved two residents, one with a cognitive mental status and the other with severe cognitive impairment. The resident with severe cognitive impairment entered the room of the other resident and physically assaulted her while she was asleep. This incident was documented in the progress notes of both residents, with the assaulted resident reporting being punched in the face and verbally abused. The facility's Abuse, Neglect, and Misappropriation of Funds Program, which emphasizes zero tolerance for abuse, was not effectively implemented in this case. The incident was reported to the Assistant Director of Nursing and the Director of Nursing via text messages shortly after it occurred. Despite the facility's commitment to ensuring the safety and well-being of residents, the abuse occurred, indicating a lapse in the protective measures that should have been in place to prevent such incidents.
Failure to Label Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure proper labeling of an enteral feeding bag for a resident with dysphagia and gastrostomy status. The resident was readmitted to the facility with specific physician orders for enteral feeding via a PEG tube. The facility's policy required that formula bottles and bags be labeled with the resident's name, date and time of initiation, and rate of administration. However, observations on multiple occasions revealed that the enteral feeding bag and free water flush bag for the resident were not labeled with the required information, including the date and time administered, the resident's name, and the infusion rate. Interviews with staff, including an LPN and the Director of Nursing, confirmed the lack of labeling on the enteral feeding and free water flush bags. The staff acknowledged that the bags should have been labeled according to the facility's policy. Despite the facility's procedures, the deficiency persisted over several days, as observed by surveyors, indicating a failure to adhere to established protocols for enteral feeding management.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain accurate records of controlled drugs for two medication carts, Medication Cart a and Medication Cart b, as required by their Controlled Drug Policy and Procedure. This policy mandates that controlled drugs be counted and recorded by the nurse coming on duty and the nurse going off duty at the end of each shift. However, the review of the December 2024 Controlled Drugs-Count Record for Medication Cart a revealed missing signatures for several shifts, specifically on 12/01/2024, 12/16/2024, 12/17/2024, and 12/18/2024. Similarly, Medication Cart b had an incomplete reconciliation on the shift of 12/17/2024. Interviews with staff confirmed these discrepancies. An LPN acknowledged the missing signatures on the controlled drugs-count record for the specified dates for Medication Cart a. The Director of Nursing also confirmed the absence of required signatures for both Medication Cart a and Medication Cart b on the noted dates. These lapses indicate a failure to adhere to the facility's policy for controlled drug reconciliation, which is crucial for ensuring the accuracy and security of controlled substances within the facility.
Failure to Monitor Resident's Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen for unnecessary medications, specifically focusing on antidepressants and anti-anxiety medications. Resident #346, who was admitted with diagnoses of major depressive disorder and anxiety, was prescribed Prozac and Buspirone. However, there was no documented evidence of side-effect monitoring for these medications on specific dates in December 2024, particularly during night shifts. This lack of documentation indicates that the facility did not ensure proper monitoring of the resident's response to these medications. Additionally, the facility did not document behavior monitoring for Resident #346 on several occasions throughout December 2024, across various shifts. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the absence of documented evidence for both behavior and side-effect monitoring during the specified times. This deficiency highlights a failure in the facility's responsibility to monitor and document the resident's condition and response to prescribed medications, which is crucial for ensuring the resident's safety and well-being.
Delay in Urinalysis Collection and Treatment Initiation
Penalty
Summary
The facility failed to ensure timely collection and processing of a urinalysis for a resident, which was ordered to investigate aggressive behavior potentially linked to a urinary tract infection (UTI). A physician's order for a urinalysis with culture and sensitivity was placed on December 5, 2024, but the urine sample was not collected until December 10, 2024. The Director of Nursing (DON) acknowledged that the sample should have been obtained on the day the order was made, December 5, 2024, but could not explain the delay. The laboratory results, which confirmed a UTI, were available on December 13, 2024, but the resident did not begin receiving the prescribed antibiotic treatment until December 16, 2024. The DON indicated that the physician should have been notified, and treatment should have commenced on December 13, 2024, when the results were received. This delay in both obtaining the sample and initiating treatment represents a failure to follow timely medical orders, potentially impacting the resident's health and well-being.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food was palatable and served at an appetizing temperature, as observed during a survey. A resident with moderate cognitive impairment expressed dissatisfaction with the taste of the food, stating that both the main and alternate meals were unappealing. During an observation, surveyors tasted an alternate meal and found the mashed potatoes and gravy to be lukewarm to room temperature, the cod fish patty to be thin and mostly breading, and the steamed broccoli to be soft and mushy. The Dietary Manager acknowledged that the alternate lunch tray was not palatable and not served at an acceptable temperature.
Deficiency in Food Labeling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper labeling and dating of opened food products, as observed during a survey. Eight food items, including jelly, peanut butter, various spices, and mustard, were found opened without any indication of the date they were opened. This lack of labeling is contrary to the facility's policy, which requires all foods to be labeled with the date they were prepared or opened, the use-by date, and product identification. The absence of such labeling poses a potential risk for foodborne illness, especially for individuals with weakened immune systems. Additionally, the facility did not maintain kitchen cooking equipment in a clean and sanitary condition. Observations revealed a clear to yellow thick substance buildup on the edges of the standing fryer, as well as on the sides of the stove and oven adjacent to the fryer. The Dietary Manager acknowledged the presence of grease buildup and confirmed that the equipment should have been kept in a sanitary manner, indicating a failure to adhere to the facility's standards for cleanliness and food safety.
Inadequate Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff when assisting residents with meals. Specifically, a Certified Nursing Assistant (CNA) was observed assisting two residents with their meals without performing hand hygiene in between. This was confirmed by the CNA, a Licensed Practical Nurse, and the Director of Nursing, all acknowledging that hand hygiene should have been performed between assisting residents with meals. The facility's policy from 2009 emphasizes hand hygiene as the primary means to prevent the spread of infections, indicating a clear deviation from established protocols. Additionally, the facility did not maintain proper handling of an indwelling urinary catheter for a resident. The resident's urinary catheter tubing and collection bag were observed lying on the floor on multiple occasions. This was confirmed by the Director of Nursing and the Administrator, who both acknowledged that the catheter tubing and bag should not have been on the floor. The resident had hospice admission orders for a Foley catheter due to urinary retention or incontinence, highlighting the importance of maintaining proper catheter care to prevent infections.
Failure to Adhere to Employment Screening Policies
Penalty
Summary
The facility failed to ensure that a staff member with a charge that barred employment was not allowed to work without a final disposition of the charge. Specifically, the facility's policy for Abuse, Neglect, and Misappropriation of Funds required pre-employment screenings to be completed on all potential employees before offering a position. The policy also stated that employment offers would not be made to individuals with felony convictions listed in state regulations. However, the facility hired a Certified Nursing Assistant (CNA) with a charge of aggravated assault with a firearm, which is a disqualifying offense under Louisiana R.S. 40:1203.3. The personnel record of the CNA revealed a hire date and a completed criminal background check, which showed an arrest for aggravated assault with a firearm. Despite this, there was no documented evidence of a disposition for the charge, and the facility did not provide any such evidence. During an interview, the Director of Nursing confirmed the CNA had a charge that barred employment and acknowledged the lack of a disposition for the charge. This oversight indicates a failure to adhere to the facility's own policies and state regulations regarding the employment of individuals with certain criminal charges.
Medication Room Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication room was locked when unattended, which is a violation of the requirement to store drugs and biologicals securely. On the morning of October 8, 2024, the door to Medication Room a was observed to be open and unattended, with a door stop placed at the base of the door. This room contained individual cubby areas with medications. Video surveillance confirmed that the Assistant Director of Nursing entered the room at 9:55 a.m., placed the door stop, and left the room at 10:02 a.m., leaving the door open and unattended until 11:35 a.m. The Director of Nursing and the Administrator confirmed the situation during an interview.
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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