Patterson Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Patterson, Louisiana.
- Location
- 910 Lia St, Patterson, Louisiana 70392
- CMS Provider Number
- 195425
- Inspections on file
- 26
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Patterson Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and dementia repeatedly accessed and ingested hazardous non-food items, such as shampoo, lotion, potting soil, and other residents' food and drinks, due to inadequate supervision. Staff and medical records documented ongoing incidents of wandering, entering other residents' rooms, and consuming unsafe substances, with staff interviews confirming awareness of the behaviors but insufficient supervision provided to prevent these events.
Several residents were unable to access their personal funds on weekends because the staff responsible for managing these funds were not present, and there was no posted information or education provided about how to obtain funds during this time.
A resident's bathroom was found to have an 8 inch by 3.5 inch hole in the wall, which remained unaddressed over several days and was not documented in the maintenance log. The administrator acknowledged the disrepair during an interview.
A resident's urine specimen was collected for UA and C&S following a provider's verbal order, but the facility did not obtain the lab results. The DON confirmed the lab had no record of receiving the specimen, and a new specimen was not collected as needed. The provider did not receive results and had to request a re-collection.
The facility did not ensure that required assistance with personal hygiene and transfers was consistently documented for three residents who needed varying levels of support with ADLs. Review of records and staff interviews confirmed that CNAs were responsible for documentation, but there were multiple instances where no evidence of provided care was recorded, despite care plans indicating the need for such assistance.
A resident with a swallowing disorder was not given the physician-ordered heavily iced liquids during meal service, instead receiving a non-iced yellow liquid. Multiple staff, including a CNA, ST, LPN, RD, and DON, confirmed that the resident should have received heavily iced liquids as per the care plan and physician's order.
The facility did not post updated nurse staffing information at the start of each shift as required, with observations showing that the information displayed was from the previous day on multiple occasions. The DON confirmed that the postings should have been current.
A cognitively impaired resident with a high risk of falls did not receive appropriate interventions to prevent falls. Despite multiple falls, the facility continued to rely on educating the resident to use the call bell system, which was unsuitable due to the resident's cognitive limitations. Staff interviews confirmed the inadequacy of the interventions and the need for updated care plan measures.
A facility failed to monitor the effectiveness and potential side effects of medications prescribed to a resident with dementia, anxiety, and depression. The resident was on multiple medications, including Haloperidol, Trazodone, Morphine, Lorazepam, and Zoloft, but there was no documented evidence of monitoring. Interviews with the DON and Corporate Clinical Specialist confirmed the oversight.
The facility failed to maintain food safety and sanitation standards, with issues including unclean kitchen equipment, improperly stored food, a cook without proper hair restraint, and expired test strips for dishware sanitization.
A resident was found to be self-administering Flonase Sensimist Nasal Suspension without a physician's order or care plan, contrary to facility policy. Despite being cognitively intact, the resident had not been assessed for self-administration, and staff confirmed the lack of necessary documentation and orders.
The facility failed to maintain safe and sanitary conditions in two shower rooms, with surveyors observing an unknown substance on shower tiles and an overflowing sharps container. A resident reported mildew in a shower stall, and staff confirmed the lack of cleanliness and safety.
A facility failed to implement OBH recommendations for a resident with mental health diagnoses, including anxiety disorder, depression, and schizophrenia. The resident was referred for a comprehensive psychiatric evaluation, but the facility did not document or conduct this evaluation, as confirmed by a Corporate Clinical Specialist.
A facility failed to involve a resident, who was cognitively intact, in the development and revision of their Comprehensive Care Plan. Despite having multiple MDS assessments, the resident reported not being notified or involved in care plan meetings. The facility's policy requires resident involvement, but no documentation was found to support this for the resident in question.
A resident with hemiplegia and hemiparesis was not provided with necessary nail care, despite being cognitively intact and requiring assistance with personal hygiene. Observations showed the resident had long nails, and interviews confirmed the resident's requests for nail trimming were not fulfilled. Facility staff acknowledged the oversight, which was contrary to the facility's nail care policy.
A resident was administered oxygen therapy without a documented physician's order, and their care plan lacked interventions for oxygen use. Facility staff confirmed the absence of an order, contrary to the facility's policy requiring verification of a physician's order for oxygen administration.
A CNA in a facility applied antifungal powder containing miconazole nitrate to a resident, contrary to the facility's policy that only licensed personnel should administer medications. The CNA was unaware that the powder contained medication and had been applying it daily. The DON confirmed this was against policy.
The facility failed to properly handle and store medications, including using an expired insulin pen, improperly securing a pill with tape, and storing medications at incorrect temperatures. Interviews with staff confirmed these practices were not compliant with protocols.
The facility did not follow its approved lunch menu and failed to get dietician approval for menu substitutions. The posted menu indicated a meal with a baked pork chop, but the approved menu listed beef roast. Residents received a meal that did not match the posted menu, and the Dietary Manager admitted to making unapproved substitutions. The Registered Dietician was not informed of these changes.
The facility failed to maintain effective infection control practices, as an LPN did not perform hand hygiene while administering medications to a resident, and a resident's urinal was not properly contained to prevent infection spread. Both incidents were confirmed by staff, highlighting lapses in adherence to infection prevention protocols.
A resident's call bell system was found to be non-functional as it was wrapped around the bed's side rail and not plugged into the wall, despite the resident's care plan requiring its use for assistance. Facility staff, including an LPN, CNA, ADON, and DON, confirmed the deficiency during interviews.
The facility failed to allow residents identified as safe smokers to smoke at their leisure, despite policy stating they could do so unsupervised. Instead, the facility imposed designated smoking times and kept smoking materials at the nurse's station. Residents expressed dissatisfaction with these restrictions, and staff confirmed the limitations, acknowledging that safe smokers should be allowed to smoke freely.
The facility failed to address grievances raised during Resident Council Meetings over three months, including issues with CNA care, mail handling, and policy changes. Despite documented complaints, the Administrator claimed no grievances were filed, and there was no evidence of resolution. Interviews revealed a fear of retaliation among residents, discouraging them from voicing concerns. The Corporate Nurse confirmed grievances should have been documented and addressed.
A resident with intact cognition reported being shoved by the facility's administrator, but the incident was not documented or reported to the state agency as required. Despite being informed, the facility's social services and administrator failed to escalate the report, breaching the facility's Abuse Prohibition Policy.
A resident with intact cognition reported being physically abused by the facility's administrator, but the incident was not promptly investigated as required by the facility's Abuse Prohibition Policy. The administrator delayed reporting the allegation to the corporate nurse, resulting in a deficiency in handling the abuse allegation.
Failure to Prevent Resident Access to Hazardous Items Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident with Alzheimer's disease, dementia, and altered mental status, resulting in repeated incidents where the resident consumed or attempted to consume hazardous non-food items. The resident's care plan and medical records documented ongoing behaviors such as wandering, entering other residents' rooms, and ingesting substances like shampoo, lotion, liquid soap, potting soil, and body wash. Despite these documented risks and the resident's cognitive impairment and poor decision-making skills, the facility did not implement sufficient supervision or environmental controls to prevent access to these hazards. Multiple progress notes and staff interviews confirmed that the resident was frequently found with inappropriate items in her mouth, including potting soil, coffee from other residents' mugs, and used cigarette butts. Staff consistently reported that the resident would grab random objects, food, and drinks belonging to others, and had a history of eating non-food items from various locations within the facility, such as the dining room, hallways, and smoking patio. Observations during the survey also showed the resident attempting to take items from used lunch tray carts and holding coffee mugs that did not belong to her. Interviews with CNAs, LPNs, and the DON revealed that the staff were aware of the resident's behaviors and the need for close supervision, with some staff indicating that one-on-one supervision was sometimes necessary but not provided. The DON acknowledged that the resident should not have been able to access other residents' rooms or their personal items, and the administrator recognized the ongoing safety issues related to the resident's behaviors. The facility's failure to provide adequate supervision and prevent access to hazardous items resulted in repeated incidents that placed the resident at risk.
Failure to Provide Resident Access to Personal Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents were able to access their personal funds on weekends, affecting four residents who were investigated for this issue. Multiple residents reported being unable to obtain money from their facility-managed personal funds during weekends, as the Business Office Manager and Human Resources staff responsible for fund access did not work on those days. Residents indicated they had to plan ahead to access funds before the weekend or were unable to obtain money when needed. Additionally, there was no signage posted to inform residents of the process for accessing personal funds, and residents had not been educated on how to request access to their funds during weekends.
Failure to Maintain Bathroom Wall in Good Repair
Penalty
Summary
The facility failed to maintain the walls of a resident's bathroom in good repair, as evidenced by the presence of an approximately 8 inch by 3.5 inch hole near the bottom of the right wall in Bathroom f. This deficiency was observed on three consecutive days, with no entries regarding the hole found in the facility's maintenance log covering the relevant period. During an interview, the administrator acknowledged that the wall should not be in disrepair. No information was provided regarding the medical history or condition of the resident(s) using the bathroom at the time of the deficiency.
Failure to Obtain and Follow Up on Laboratory Test Results
Penalty
Summary
The facility failed to obtain laboratory test results for one resident who was ordered to have a urine specimen collected for urinalysis (UA) and culture and sensitivity (C&S). A nurse received a verbal order from the resident's medical provider to collect the specimen, and the specimen was collected the following day. However, there was no documented evidence that the facility obtained the results of the UA and C&S from the collected specimen. Upon inquiry, the Director of Nursing confirmed that the laboratory had no record of receiving the urine specimen, and a new specimen was not collected as required. The resident's medical provider also confirmed that the results were not received and had to request a re-collection of the specimen.
Failure to Document ADL Assistance for Multiple Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of activities of daily living (ADL) for three residents who required varying levels of assistance with transfers and personal hygiene. According to the facility's own Charting and Documentation policy, all services provided, progress toward care plan goals, and any changes in a resident's condition must be documented in the medical record. However, record reviews revealed multiple instances where there was no documented evidence that required assistance with personal hygiene and transfers was provided during specific shifts for all three residents. These residents had documented ADL self-care performance deficits and required supervision, partial to moderate, or total assistance for transfers and personal hygiene as outlined in their care plans and Minimum Data Set (MDS) assessments. Interviews with the MDS Coordinator and the Director of Nursing confirmed that Certified Nursing Assistants (CNAs) were responsible for documenting the assistance provided, and acknowledged that documentation was missing for the identified dates and shifts. The lack of documentation affected all three residents, each of whom had care plans specifying their need for assistance with ADLs, and the missing records spanned multiple days and shifts over several months.
Failure to Provide Prescribed Diet for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with oropharyngeal phase dysphagia, who had a physician's order for a regular diet with heavily iced liquids, was not provided with the prescribed diet. Observations during meal service revealed that the resident was repeatedly offered a yellow liquid without ice by a certified nursing assistant. After consuming the non-iced liquid, the resident was observed to clear her throat and cough. The speech therapist, present during one of the observations, confirmed that the liquid did not meet the prescribed requirement for heavily iced liquids. Interviews with facility staff, including the speech therapist, LPN, registered dietician, and director of nursing, all confirmed that the resident should have received heavily iced liquids as per the physician's order. The failure to provide the correct diet was contrary to the facility's policies on therapeutic diets and assistance with meals, which require adherence to physician orders and individualized resident needs.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information at the beginning of each shift daily as required. Observations on multiple occasions revealed that the posted nurse staffing information was not updated for the current day, with postings dated for the previous day instead. Specifically, on two separate dates, the nurse staffing information displayed was from the day before, rather than reflecting the current staffing. During an interview, the DON acknowledged that the nurse staffing information should have been posted on the days in question as required.
Inadequate Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure appropriate interventions were in place to prevent falls for a cognitively impaired resident with a high risk of falls. The resident, who had a history of falls and a previous fracture, was admitted with a moderate cognitive impairment and was dependent on staff for toileting transfers. Despite being identified as high risk for falls, the interventions implemented were primarily focused on educating the resident to use the call bell system for assistance, which was not suitable given the resident's cognitive limitations. The resident experienced multiple falls, including falls with injury, yet the care plan interventions remained unchanged and inappropriate. Interviews with facility staff, including the MDS Coordinator and an LPN, confirmed that the interventions were not appropriate for the resident's cognitive impairment. The staff acknowledged that the care plan should have been updated with new, suitable interventions to address the resident's fall risk effectively.
Failure to Monitor Medication Effectiveness and Side Effects
Penalty
Summary
The facility failed to monitor the effectiveness and potential side effects of several medications prescribed to a resident, leading to a deficiency. The resident, who was admitted with diagnoses including unspecified dementia, anxiety disorder, depression, restlessness, and agitation, was prescribed multiple medications such as Haloperidol, Trazodone, Morphine, Lorazepam, and Zoloft. Despite these prescriptions, there was no documented evidence in the resident's Electronic Medical Record (EMR) or the facility's records that the resident was monitored for the effectiveness and possible side effects of these medications. Interviews with the Director of Nursing and the Corporate Clinical Specialist confirmed the lack of monitoring for the resident's medication regimen. Both acknowledged that the resident should have been monitored for the effectiveness and potential side effects of the medications, but this was not done. This oversight was identified during a review of the resident's records for November and December 2024, highlighting a failure in the facility's medication management practices.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to food safety and sanitation. Observations revealed that the hood fan in the kitchen had an unknown white and orange/red substance on its surface, and the double fryer had a white substance on the outside and a brown substance on the back ledge. These findings were confirmed by the facility's administrator, who acknowledged that these areas should have been kept clean and sanitary. Additionally, the facility's cooler was found to have improperly stored food items, including a bag of frozen fish, sliced turkey, and shredded lettuce, all of which lacked open dates and were not properly contained. The dietary manager confirmed these issues. Furthermore, a dietary cook was observed preparing food without a proper hair restraint for his beard, and the facility's Auto-Chlor test strips used for dishware and sanitization were expired, as confirmed by the dietary manager.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically Flonase Sensimist Nasal Suspension, which was observed at the resident's bedside. The facility's policy requires that a resident may self-administer medications only if the attending physician, along with the interdisciplinary care planning team, determines that the resident has the decision-making capacity to do so safely. However, there was no evidence of a physician's order or care plan addressing the self-administration of medications for the resident, despite the resident being cognitively intact with a Brief Interview of Mental Status score of 15. Interviews with facility staff, including an LPN, the MDS Coordinator, a Clinical Nurse Specialist, and the Director of Nursing, confirmed that the resident did not have a physician's order or care plan for self-administration of medications. The resident indicated she had been self-administering the nasal spray as needed, although she was supposed to have it administered daily. The staff acknowledged that the resident should not have been self-administering the nasal spray without the appropriate assessments and orders in place.
Facility Fails to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain shower rooms in a safe and sanitary condition, as observed in two of the three shower rooms reviewed. In shower room y, surveyors noted an unknown black/brown substance on the surface and around the edges of the shower tiles. Similarly, shower room z had three shower stalls in use with the same black/brown substance present. Interviews with the housekeeping manager and the housekeeper responsible for shower room z confirmed the presence of the substance and acknowledged that the stalls should have been cleaned. A resident also reported noticing mildew in the shower room z stall they used, indicating a lack of cleanliness by the housekeeping staff. Additionally, in shower room y, a sharps container was found overflowing with used shaving razors, with a red/brown substance dripping down its lid. The LPN interviewed was unaware of who was responsible for replacing the full sharps container and agreed that the situation was neither safe nor sanitary. The Assistant Director of Nursing confirmed that the sharps container should not have been overflowing, indicating a lapse in maintaining a safe environment for residents.
Failure to Implement OBH Recommendations for Psychiatric Evaluation
Penalty
Summary
The facility failed to implement recommendations from the Office of Behavioral Health (OBH) for a resident with a mental health diagnosis. The resident, identified as Resident #39, was admitted with diagnoses including anxiety disorder, depression, and schizophrenia. A Level II Pre-admission Screening and Resident Review (PASARR) indicated that the resident was referred to OBH for psychiatric treatment recommendations. OBH recommended a comprehensive psychiatric evaluation for the resident. However, a review of the resident's Electronic Medical Record (EMR) showed no documented evidence that this evaluation was completed. This was confirmed in an interview with the Corporate Clinical Specialist, who acknowledged that the evaluation had not been conducted as recommended by OBH.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was involved in the development and revision of their Comprehensive Care Plan. The facility's policy on care plans, last reviewed in November 2024, mandates resident and/or representative involvement in the care planning process. This includes reviewing and updating the care plan when there is a significant change in the resident's condition, when desired outcomes are not met, upon readmission from a hospital stay, and at least quarterly with the required MDS assessment. However, for Resident #58, who was cognitively intact with a BIMS score of 15, there was no documented evidence of participation or notification of care plan meetings during the specified assessment periods. Resident #58 had several MDS assessments, including an annual review, quarterly reviews, and an entry assessment, yet reported not being involved or notified of care plan meetings. Interviews with the resident and the social worker confirmed the lack of involvement and documentation. The social worker acknowledged that Resident #58 was his own responsible party, yet the facility could not provide evidence of his participation or notification in the care planning process, leading to the identified deficiency.
Failure to Provide Nail Care to Resident
Penalty
Summary
The facility failed to provide necessary nail care to a dependent resident, identified as Resident #76, who was admitted with hemiplegia and hemiparesis following a cerebral infarction. The resident was cognitively intact, as indicated by a BIMS score of 15, and required supervision and assistance with personal hygiene due to self-care performance difficulties. Despite these needs, observations on two consecutive days revealed that the resident had excessively long nails, with no documented evidence of nail care being provided. Interviews conducted with the resident and facility staff confirmed the deficiency. The resident expressed that he had requested nail trimming from the staff, but his request was not fulfilled, causing him discomfort. Both the Director of Nursing and the Assistant Director of Nursing acknowledged that the staff should have trimmed the resident's nails upon request, as per the facility's policy on nail care, which mandates daily cleaning, regular trimming, and documentation in the resident's medical record.
Failure to Develop Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop a plan of care for a resident who was receiving oxygen therapy. Observations over several days revealed that the resident was administered oxygen at varying rates per nasal cannula, yet there was no documented physician's order for this oxygen therapy. Additionally, the resident's care plan for altered respiratory status did not include any interventions for oxygen use. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the absence of a physician's order for the oxygen administration. The facility's policy on oxygen administration requires verification of a physician's order as the first step, which was not followed in this case.
Unlicensed Personnel Administered Medication
Penalty
Summary
The facility failed to ensure that only licensed personnel administered medications, as observed with a resident who had an order for antifungal powder to be applied to specific areas of the body. The facility's policy stated that only licensed or permitted individuals could prepare, administer, and document medication administration. However, a Certified Nursing Assistant (CNA) was observed applying the antifungal powder, which contained miconazole nitrate, under the resident's right breast. The resident confirmed that CNAs had been applying the powder as needed. The CNA admitted to applying the powder daily and was unaware that it contained medication, indicating a lack of awareness of the facility's policy. The Director of Nursing confirmed that the CNA should not have applied the antifungal powder.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications, as evidenced by several observations. An insulin pen was found on a medication cart with an open date that exceeded the 28-day usage period, indicating it should have been discarded. Additionally, a pill from a blister pack was opened and then improperly secured back into the pack with tape, which is not an acceptable practice. Interviews with the LPN and the Director of Nursing confirmed these practices were not in compliance with the facility's medication handling protocols. Furthermore, the facility's medication refrigerator was observed to be storing medications at an improper temperature of 50 degrees Fahrenheit, which is above the recommended range for storing insulin and influenza vaccines. The Daily Temperature Log confirmed that the refrigerator's temperature was consistently outside the acceptable range of 36 to 46 degrees Fahrenheit. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the medications were not stored at the proper temperature, which could potentially compromise their efficacy.
Failure to Follow Approved Menu and Obtain Dietician Approval for Substitutions
Penalty
Summary
The facility failed to adhere to its approved lunch menu and did not obtain the necessary approval for menu substitutions from the facility's dietician. On the specified date, the posted menu in the dining room indicated that a meal consisting of a baked pork chop, broccoli and cauliflower, a dinner roll, and a frosted cake would be served. However, the approved menu for that day was supposed to include beef roast, mashed potatoes, broccoli and cauliflower with cheese, a dinner roll, and a frosted cake. The actual meal served to the residents included a baked pork chop, mashed potatoes, broccoli and cauliflower, and a frosted cake, which did not match the posted menu. Interviews with residents and staff revealed discrepancies in the meal served. A resident noted that the chopped meat on her mechanical soft diet ticket was not a pork chop as indicated on the posted menu, and the broccoli and cauliflower lacked cheese. The Dietary Manager admitted to substituting the beef roast with a grilled pork chop and acknowledged that the menu revision was not approved by the facility's dietician. The Registered Dietician confirmed that she was not informed of the menu change and that such revisions should have been recorded and approved on the day they were made.
Infection Control Deficiencies in Medication Administration and Urinal Containment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents. In the first incident, a Licensed Practical Nurse (LPN) did not perform hand hygiene while administering medications to a resident. The LPN was observed cutting Tylenol, cranberry, and Carafate tablets in half without using gloves or performing hand hygiene before handling the medications. This was confirmed by the LPN and the Director of Nursing, who acknowledged that hand hygiene should have been performed before administering medications. In the second incident, a resident's urinal was found hanging on a handrail in the bathroom without being contained in a plastic bag, which is necessary to prevent the spread of infection. A Certified Nursing Assistant (CNA) confirmed that the urinal should have been contained in a plastic bag, and the Director of Nursing also indicated that the urinal should have been properly contained for infection control compliance.
Non-functional Call Bell System for Resident
Penalty
Summary
The facility failed to ensure a functional call bell system was available for a resident who required assistance with activities of daily living. The resident's care plan, which was last revised in December 2024, included an intervention to encourage the use of the call bell for assistance. However, observations on multiple occasions revealed that the resident's call light was wrapped around the bed's side rail and not plugged into the wall, rendering it non-functional. Interviews with facility staff, including an LPN, a CNA, the Assistant Director of Nursing, and the Director of Nursing, confirmed that the call light was not plugged in and should have been to ensure functionality. The staff acknowledged that the call light should not have been wrapped around the bed's side rail and needed to be plugged into the wall to be operational, indicating a lapse in ensuring the resident's ability to call for assistance as per their care plan.
Facility Restricts Safe Smokers' Rights
Penalty
Summary
The facility failed to uphold the rights of residents identified as safe smokers by not allowing them to smoke at their leisure, despite being assessed as capable of doing so unsupervised. The facility's smoking policy, revised in March 2024, states that residents deemed safe smokers can keep their smoking supplies and smoke in designated areas at their leisure. However, interviews and observations revealed that the facility imposed designated smoking times and kept all residents' smoking materials at the nurse's station, regardless of their safe smoker status. Four residents, all with intact cognition as indicated by their Brief Interview of Mental Status (BIMS) scores, were identified as safe smokers through their Smoking Safety Evaluations. Despite this, they were restricted to smoking only at specific times set by the facility. Interviews with the residents and staff confirmed that these restrictions were in place, and residents expressed dissatisfaction with the limitations on their smoking rights. The Director of Nursing acknowledged that safe smokers should be allowed to smoke at their leisure, yet the facility continued to enforce the designated smoking times.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and act upon grievances promptly as per their grievance procedure. Over a three-month period, grievances were raised during Resident Council Meetings, including issues such as mail being opened before residents received it, dissatisfaction with bath/shower schedules, inadequate CNA care, delayed response to call lights, and unavailability of coffee. Additional complaints included CNAs not assisting residents, placing them in bed in day clothes, and speaking disrespectfully. There were also grievances about a sudden change in the smoking policy, poor linen conditions, and the Administrator's perceived arrogance. Despite these documented grievances, the Administrator claimed no grievances had been filed, and there was no evidence of resolution. Interviews revealed a lack of formal grievance forms and a fear of retaliation among residents, which discouraged them from voicing concerns. The Activities Director confirmed that grievances from Resident Council Meetings were communicated to the Administrator, yet no actions were taken. The Social Services staff, designated as the Grievance Officer, also reported no formal grievances filed. A resident expressed fear of retaliation, stating that complaints were not addressed and that the Administrator disclosed grievances to staff in front of residents. The Corporate Nurse confirmed that grievances should have been documented and addressed, but they were not.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the required state survey agency. The incident involved a resident with an intact cognitive status, who reported being shoved by the facility's administrator. Despite the resident's report and subsequent confirmation by a social worker at a behavioral hospital, the incident was not documented in the facility's incident log or reported to the state agency as required by the facility's Abuse Prohibition Policy. Interviews revealed that the facility's social services were informed of the incident but did not escalate it further. The administrator, who was aware of the allegation, failed to report it, stating he did not anticipate the situation escalating. The corporate nurse confirmed that the incident should have been reported within two hours of awareness, but it was not reported until much later, indicating a clear breach of protocol.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of staff-to-resident physical abuse involving one resident. The facility's Abuse Prohibition Policy mandates a comprehensive investigation of any alleged or suspected abuse, with prompt notification to the appropriate authorities. However, in this case, the allegation was not properly investigated. The resident, who had an intact cognitive status as indicated by a BIMS score of 14, reported being grabbed and pushed by the facility's administrator during an altercation. This allegation was communicated to the facility's social worker by the resident's social worker at a behavioral hospital. Despite being informed of the allegation, the facility's administrator did not take immediate action to investigate or report the incident. The administrator was aware of the allegation on the day it was reported but delayed notifying the corporate nurse until a week later. The corporate nurse confirmed that the investigation should have commenced upon the initial report of the allegation. The failure to initiate a timely investigation resulted in a deficiency in the facility's handling of the abuse allegation.
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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