Resthaven Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bogalusa, Louisiana.
- Location
- 1301 Harrison Street, Bogalusa, Louisiana 70427
- CMS Provider Number
- 195624
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Resthaven Living Center during CMS and state inspections, most recent first.
Surveyors identified that two residents received incorrect medication dosages during an observed med pass, resulting in a 12% medication error rate. One LPN administered a 25 mg dose of Sertraline instead of the ordered 50 mg, while another LPN gave a 50 mg Zinc capsule instead of 220 mg and a 10 mcg Vitamin D3 tablet instead of 1250 mcg. In each case, the nurses later confirmed, after reviewing the MAR and medication packaging, that they had not verified the correct dosages before administration, contrary to facility policy requiring multiple label checks to ensure the right medication and dose.
Surveyors identified unsanitary food service conditions when an ice machine contained ice mixed with visible pink sludge, which the dietary manager acknowledged was not sanitary despite recent cleaning. In addition, a cook demonstrated washing pots and pans in a 3-compartment sink using an incorrect sequence of wash, sanitize, and rinse, while the sanitizer dispenser was installed in the middle basin labeled as the rinse sink instead of the final basin. The dietary manager and administrator both confirmed that the ice machine should be clean and that the correct 3-compartment sink process is wash, rinse, then sanitize.
Surveyors found that a bulk grease disposal container located outside behind the kitchen was in poor condition, with its lid left open and black grease accumulated on top of the container and on the surrounding concrete, mixed with leaves. The dietary manager acknowledged that the container had been in this unsanitary condition for several months, with grease present on and around it, and confirmed the lid remained open. The administrator also confirmed awareness that the lid had been left open, that rain caused grease to spill over onto the concrete, and that the container had been in poor condition for an extended period, resulting in improper containment of refuse with the potential to affect 82 residents.
Surveyors found that a resident shower room (Shower Room A) was not maintained in a sanitary and comfortable condition, with a black, fuzzy substance observed on the tile where the wall met the floor below the shower head. A CNA confirmed the substance had been present for a long time and described the room as neither comfortable nor sanitary, stating that both maintenance and the administrator were aware of the ongoing issue. The maintenance staff member acknowledged the substance had been present for months in a shower room used by residents and agreed it was not being properly maintained, and the administrator confirmed awareness of the problem and that the substance should not have been present.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required accessible call systems. One resident with moderate cognitive impairment and multiple conditions, including osteoarthritis and prior cerebral infarction, was observed with her call light on the floor, out of reach, despite being able to use it. Another resident with severe cognitive impairment, mobility issues, and diabetic polyneuropathy was observed in a geri-chair with the call light rolled up on a bedside table, also out of reach, even though she could use it to request help. Staff, including a CNA, a supervisor, and the DON, confirmed that both residents were capable of using their call lights and that facility policy requires call lights to be easily reachable at all times.
A resident’s Discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, despite nursing notes documenting that the resident left the facility via wheelchair using personal transportation and against medical advice. During interviews, the MDS nurse acknowledged the discharge status should have been coded as a discharge to home/community, and the DON stated an expectation that MDS nurses complete assessments to accurately reflect each resident’s discharge status.
A resident with documented mental health conditions, including Bipolar Disorder, Depression, and Anxiety Disorder, was readmitted and had a PASRR Level I form completed by an LPN using only hospice referral records, which did not list Bipolar Disorder. The LPN did not review the resident’s prior admission records, where Bipolar Disorder was clearly documented, resulting in a PASRR Level I that listed only Major Depression and Anxiety Disorder. Upon review, quality improvement staff and the LPN confirmed that the Bipolar Disorder diagnosis should have been included but was omitted.
A resident with an indwelling port and sacral wound infection was on Enhanced Barrier Precautions (EBP) with posted signage and physician orders requiring gown and gloves for high-contact care, including device care or use. An LPN was observed administering IV Vancomycin through the resident’s chest port while not wearing a gown, contrary to the facility’s EBP policy and the instructions on the EBP sign. In a subsequent interview, the LPN acknowledged that a gown should have been worn, and the DON confirmed that appropriate PPE is required for residents on EBP, including during IV medication administration via a port.
The facility failed to employ a certified dietary manager, as the previous manager was fired weeks ago, and the acting manager lacked the necessary certification. The administrator confirmed no staff held the required certification, potentially affecting 84 residents consuming food from the kitchen.
The facility failed to store food according to professional standards, potentially affecting 84 residents. Expired items, including cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, were found in the kitchen. The facility's policy requires safe food handling practices, but these items were not discarded as they should have been, as confirmed by S1ADM.
A resident with Glaucoma was inaccurately assessed in their MDS, which indicated clear speech and adequate vision. However, therapy notes and staff interviews confirmed the resident had slurred speech and inadequate vision. The ADON acknowledged these issues, highlighting the need for accurate MDS coding.
A facility failed to change a resident's oxygen tubing and humidifier bottle as per physician orders, which required weekly changes every Sunday night. An observation revealed that the equipment was not changed on the scheduled date, and an LPN confirmed the oversight. The DON was notified of the failure to adhere to the schedule.
The facility failed to accurately document the MAR for two residents, leading to discrepancies in their medical records. One resident's oxygen equipment was not changed as recorded, and another resident's lab test was documented without being conducted. The involved LPNs confirmed the inaccuracies, and the DON verified the errors.
The facility failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. Two CNAs were observed providing care without wearing gowns, despite facility policy and signage indicating the requirement. Interviews confirmed staff awareness of the PPE requirement, yet compliance was not maintained.
The facility did not ensure that the most recent survey results were available for resident review. An observation revealed that the State Survey Binder only contained results from 2022, missing the 2023 annual recertification and 2024 complaint surveys. Interviews with a CNA and the DON confirmed the absence of these documents, which should have been accessible to residents.
The facility did not post the current nurse staffing data, as observed on a bulletin board by the nurses' station. The report was dated the previous day, and both the Administrator and the DON confirmed the oversight, acknowledging that the current report should have been posted.
The facility failed to document neurological assessments after unwitnessed falls for two residents. Despite staff claims of performing neuro checks, no documentation was found for one resident, and incomplete documentation was found for another. The DON confirmed the absence and incompleteness of these records, indicating a failure to adhere to the facility's policy.
The facility failed to limit PRN orders for psychotropic medications to 14 days and did not indicate the duration for the PRN orders for a resident with Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety. Interviews confirmed that the facility did not follow its policy requiring prescriber evaluation and duration documentation for PRN psychotropic medications.
The facility failed to ensure accurate resident assessments. A resident diagnosed with Major Depressive Disorder had an MDS assessment that did not reflect this active diagnosis. Staff responsible for MDS assessments confirmed the inaccuracy.
The facility failed to maintain accurate records when an LPN did not document the administration of Morphine for a resident with multiple diagnoses, including Dementia and Polyosteoarthritis. The LPN confirmed administering the medication but did not record it on the MAR, as expected by the Director of Nursing.
The facility failed to designate a staff member to coordinate care with hospice representatives, resulting in an incomplete hospice binder for a resident. Interviews with staff confirmed the absence of a designated coordinator and missing hospice plan of care documents.
Medication Administration Errors Resulting in 12% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 12% during an observed medication pass. Surveyors observed 25 medication administration opportunities and identified 3 errors involving two residents. Facility policy on administering medications, revised April 2019, states that medications are to be administered safely, timely, and as prescribed, and that the individual administering the medication must check the label three times to verify the right resident, medication, dosage, time, and route before administration. For one resident, an LPN administered Sertraline HCL 25 mg by mouth instead of the ordered Sertraline HCL 50 mg once daily. The nurse later reviewed the physician’s orders and the medication card and confirmed that the dose given was incorrect and that she had failed to verify the dosage prior to administration. For another resident, a different LPN administered Zinc 50 mg instead of the ordered Zinc Sulfate 220 mg, and Vitamin D3 10 mcg instead of the ordered Vitamin D3 1250 mcg given on specific mornings. This nurse also confirmed, upon review of the physician’s orders and medication containers, that both dosages were incorrect and acknowledged she had not checked the medication dosages prior to administration. The DON stated he expected staff to check medications against physician orders prior to administration and confirmed medications should be given in the correct dosage as ordered by the physician.
Unsanitary Ice Machine and Improper Three-Compartment Sink Use
Penalty
Summary
Surveyors found that the facility failed to store, prepare, and distribute food under sanitary conditions in the kitchen, affecting the ice machine and pot and pan sanitation. During observation of the kitchen ice machine, surveyors noted a low level of ice mixed with pink sludge, including visible pink sludge in the right front corner of the machine; the dietary manager confirmed the presence of the pink sludge and acknowledged it was not sanitary, despite stating the machine had been serviced and cleaned two days earlier. In a separate observation of pot washing at the 3-compartment sink, a cook demonstrated her process and stated she washed, sanitized, and rinsed pots and pans, while the sanitation dispenser was actually installed in the second sink labeled “rinse,” rather than in the third sink. The dietary manager confirmed that the sanitizer was in the wrong compartment and that the correct sequence for the 3-compartment sink should be wash, rinse, then sanitize, and the administrator confirmed that the ice machine should not have pink sludge and that the 3-compartment sink should be used in the proper wash, rinse, sanitize order.
Improper Maintenance and Containment of Bulk Grease Disposal Container
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and containment of grease waste when they observed a large bulk grease disposal container located outside next to the facility wall behind the kitchen with its lid open. The container had a large amount of black grease on top and on the surrounding concrete area, with leaves mixed into the spilled grease. During interview, the dietary manager stated the bulk grease container was in poor condition, confirmed the lid was open, and acknowledged that grease had been present on top of the container and on the surrounding concrete area since September 2025, describing the situation as unsanitary. In a separate interview, the administrator confirmed awareness of the bulk grease container’s location and condition, stating that the lid had been left open and that rain caused grease to spill over onto the surrounding concrete, and further confirmed the container had been in poor condition for some time and needed to be removed. This deficient practice involved failure to ensure refuse containers were in good condition and that waste was properly contained, and it had the potential to affect 82 residents residing in the facility.
Failure to Maintain Sanitary and Comfortable Resident Shower Room
Penalty
Summary
The facility failed to ensure that Shower Room A was maintained in a safe, sanitary, and comfortable condition for residents, staff, and the public. During an observation on 01/13/2026 at 3:00 p.m., surveyors noted a black, fuzzy substance on the tile below the shower head where the wall tile met the floor in Shower Room A. At 3:03 p.m., a CNA (S6CNA) confirmed the presence of this substance, stated that Shower Room A was not a comfortable and sanitary environment, and reported that the black fuzzy substance had been present for a long time and was an ongoing problem. She further stated that the maintenance staff member (S7MNT) and the administrator (S1ADM) were both aware of the condition of Shower Room A. At 3:30 p.m., S7MNT confirmed he was aware that Shower Room A, which was used by residents, had a black fuzzy substance on the tile where the wall met the floor and that it had been present for months, acknowledging that the room was not maintained in a comfortable and sanitary manner. At 4:03 p.m., S1ADM also confirmed awareness of the black fuzzy substance in Shower Room A and acknowledged that it should not have been present and that the shower room should have been maintained in a comfortable and sanitary manner. No specific residents, medical histories, or clinical conditions were described in relation to the use of Shower Room A, only that it was a resident shower room used by residents and that its condition did not meet sanitary and comfort standards.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by facility policy and individual care plans. The facility’s policy on the Resident Call Light System, revised 06/2023, states that staff must ensure the call light is easily reachable by the resident. Resident #2, admitted with multiple diagnoses including bilateral primary osteoarthritis of the hip, mild neurocognitive disorder with behavioral disturbance, vertebral compression fractures, intellectual disabilities, schizophrenia, and cerebral infarction, had an MDS BIMS score of 11, indicating moderate cognitive impairment. Her care plan specified that she was to have a working and reachable call light and be encouraged to use it for assistance as needed. On 01/12/2026 at 9:40 a.m., surveyors observed Resident #2’s call light on the floor and not within her reach. During an interview at 9:50 a.m., S13CNA confirmed that Resident #2 was able to use the call light and that it was not within her reach. Resident #51, admitted with diagnoses including difficulty in walking, other lack of coordination, primary generalized osteoarthritis, type 2 diabetes mellitus with diabetic polyneuropathy, and muscle wasting and atrophy, had an MDS BIMS score of 7, indicating severe cognitive impairment. Her care plan documented that she required staff assistance with ADLs, was to have a working, reachable call light, and was to be encouraged to use the call light for assistance. On 01/12/2026 at 9:01 a.m., surveyors observed Resident #51 sitting in a geri-chair with her call light rolled up on the bedside table, not within her reach. At 9:20 a.m., S12SUP confirmed that the call light was not within the resident’s reach, stated it should have been, and confirmed that Resident #51 was capable of using the call light to call for assistance. On 01/14/2026 at 10:25 a.m., S2DON acknowledged awareness that the call lights for both residents had been found out of reach and stated that the facility’s process is for staff to place call lights within residents’ reach before exiting the room and to ensure call lights are within reach at all times.
Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s assessment accurately reflected the resident’s discharge status. Review of the Discharge MDS assessment for Resident #92, with an ARD of 12/10/2025, showed the resident was coded as having been discharged to a short-term general hospital. However, nursing notes documented that on 12/10/2025 at 11:20 a.m., the resident left the facility via wheelchair using his own transportation. In an interview, the MDS nurse (S9MDS) confirmed that the resident had left the facility against medical advice and that the Discharge MDS was inaccurately coded, stating it should have indicated a discharge to home/community instead of to a hospital. The DON (S2DON) stated he expected MDS nurses to complete all assessments to accurately reflect each resident’s discharge status. This inaccurate coding of the discharge location for Resident #92 on the Discharge MDS constituted the identified deficiency in ensuring accurate resident assessments.
Failure to Include Bipolar Disorder Diagnosis on PASRR Level I Evaluation
Penalty
Summary
The facility failed to ensure that a resident with an identified mental health diagnosis was accurately referred for a PASRR Level II evaluation, resulting in an incomplete PASRR Level I form. The resident was initially admitted with documented diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder, and later readmitted with the same conditions. However, review of the PASRR Level I form completed on 07/30/2025 showed that only Major Depression and Anxiety Disorder were listed, and the Bipolar Disorder diagnosis was omitted. The LPN who completed the PASRR Level I form stated she relied solely on clinical records from the referring hospice agency, which did not list Bipolar Disorder, and did not review the resident’s initial admission records because she did not have access to them at that time. Upon later review of the initial admission clinical records, both the LPN and the quality improvement staff member confirmed that Bipolar Disorder had been an established diagnosis and should have been included on the PASRR Level I form but was not.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, revised in 03/2024, states that EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO), including device care or use such as central lines and ports. Resident #95’s clinical record showed an order to implement and maintain EBP during high-contact care starting 11/19/2025, an order allowing access to a port dated 08/24/2023, and an order for daily IV Vancomycin for a sacral wound infection dated 01/02/2026. An EBP sign was posted on the resident’s door, instructing that staff must wear gloves and a gown for high-contact activities including device care or use. On 01/13/2026 at 1:02 p.m., a surveyor observed an LPN (S4LPN) administering IV Vancomycin via the resident’s right chest port without wearing a gown, despite the EBP signage and the resident’s active EBP orders related to his port and wounds. During an interview immediately afterward, the LPN confirmed that the resident was on EBP due to his port and wounds and acknowledged that she should have worn a gown while providing direct resident care but did not. Later, the DON (S2DON) stated that when a resident is on EBP, he expected staff to wear appropriate PPE when providing direct resident care, confirmed that EBP is initiated for residents with indwelling medical devices such as a port, and further confirmed that appropriate PPE should be worn during IV medication administration through a port.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to manage the food and nutrition service, as evidenced by the absence of a certified dietary manager. This deficiency was identified during interviews and record reviews, revealing that the previous dietary manager had been fired 2-3 weeks prior, and the acting manager, S3DA, did not possess certification in food service or dietary management. Furthermore, the facility administrator, S1ADM, confirmed that neither he nor any other staff members held the necessary certification. This lack of qualified personnel had the potential to impact the 84 residents who consumed food prepared by the facility's kitchen.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 84 residents who were served meals from the kitchen. During an observation of the kitchen food preparation area, several expired items were found, including opened containers of cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, all of which had passed their manufacture expiration dates. The facility's policy on Food Receiving and Storage, revised in 2014, mandates that foods be received and stored in compliance with safe food handling practices. An interview with S1ADM confirmed that 84 residents eat from the kitchen and acknowledged that the expired items should have been discarded but were not.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status, specifically for one resident diagnosed with Glaucoma. The resident's quarterly MDS inaccurately indicated clear speech and adequate vision, despite therapy progress notes and multiple staff interviews confirming the resident had slurred speech and inadequate vision. Interviews with the resident and various staff members, including a physical therapist, occupational therapist, and speech therapist, consistently noted the resident's slurred speech and vision issues. The Assistant Director of Nursing also acknowledged the resident's slurred speech and vision loss, emphasizing the importance of accurate MDS coding.
Failure to Change Oxygen Tubing and Humidifier Bottle as Scheduled
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. The resident's physician orders required that the oxygen tubing and humidifier bottle be changed every Sunday night and as needed for contamination. However, an observation on 12/09/2024 revealed that the oxygen tubing and humidifier bottle were labeled with the date 12/01/2024, indicating they had not been changed as required on 12/08/2024. An LPN confirmed the oversight during an interview, acknowledging that the change should have occurred but did not. The Director of Nursing was also informed of the failure to adhere to the scheduled change.
Inaccurate Documentation in MAR for Two Residents
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for two residents, leading to discrepancies in their medical records. For Resident #3, who was admitted with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma, the MAR indicated that oxygen tubing and humidifier bottles were changed on a specific date. However, observations revealed that the equipment was not changed as documented, with the items still labeled from a previous date. The LPN responsible for the documentation confirmed that the change did not occur as recorded. Similarly, for Resident #290, who was on long-term anticoagulant therapy, the MAR inaccurately reflected that a PT/INR lab test was collected on a certain date. However, there were no lab results to support this entry, and the laboratory confirmed that no such test was conducted on that date. The LPN involved acknowledged the error in documentation, and the Director of Nursing confirmed the inaccuracies in the MAR, emphasizing that all records should accurately reflect the services provided.
Inadequate PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members while providing care to a resident under Enhanced Barrier Precautions (EBP). Specifically, the facility's policy on transmission-based precautions required staff to wear gloves and gowns during high-contact activities such as dressing and transferring residents. However, during an observation, two certified nursing assistants (CNAs) were seen dressing, emptying a urostomy bag, and transferring a resident without wearing the required gowns. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the staff was aware of the requirement to wear gowns when providing direct care to residents on EBP, yet they failed to comply with this protocol. The resident in question had been admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and ileostomy status, necessitating the use of EBP to prevent infection transmission. Despite the presence of signage on the resident's door indicating the need for PPE, the staff did not adhere to the facility's infection control policy, leading to the identified deficiency.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results of the most recent annual survey and complaint surveys were available for resident review. During an observation on December 8, 2024, it was noted that the State Survey Binder at the nurse's station only contained survey results from December 8, 2022. Interviews with a CNA and the Director of Nursing confirmed that all survey results were supposed to be kept in this binder. However, upon review, it was confirmed that the survey results from the annual recertification survey dated November 29, 2023, and the complaint surveys dated April 23, 2024, and May 31, 2024, were missing from the binder and had not been made available for resident review as required.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that the current nurse staffing data was posted daily, which had the potential to affect any of the 85 residents residing in the facility. On the morning of December 9, 2024, an observation revealed that the Daily Staffing Report posted on the bulletin board by the nurses' station was dated December 8, 2024, indicating it was not current. Interviews conducted with the Administrator (S1ADM) and the Director of Nursing (S2DON) confirmed that the posted staffing report was outdated and acknowledged that the current report had not been posted as required.
Failure to Document Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure services were provided to meet quality professional standards for two residents reviewed for falls. Specifically, the facility did not document neurological assessments after unwitnessed falls for Resident #1 and Resident #3. Resident #1, who had diagnoses including repeated falls, cerebrovascular disease, and hemiplegia, experienced unwitnessed falls on three occasions. Despite claims from staff that neurological checks were performed, no documentation was found in the clinical records. Interviews with the LPNs and the DON confirmed the absence of documented neurological assessments for these incidents. Resident #3, who had diagnoses including polyosteoarthritis, dementia, and difficulty in walking, experienced multiple unwitnessed falls. The facility's documentation of neurological assessments for these falls was incomplete. The DON confirmed that neuro checks should be completed and documented at specific intervals following unwitnessed falls, but the records for Resident #3 did not meet these requirements. This lack of proper documentation indicates a failure to adhere to the facility's policy on falls and neurological assessments.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications. Specifically, the facility did not limit PRN orders for psychotropic drugs to 14 days and did not indicate the duration for the PRN orders for one resident. Resident #3, who had diagnoses including Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety, had active PRN orders for Lorazepam and Temazepam without documented end dates. The facility's policy required that PRN psychotropic medications be limited to 14 days and that the prescriber evaluate the resident before extending the order and provide a duration for the pharmacotherapy. However, this policy was not followed for Resident #3's medications. Interviews with the Consultant Pharmacist and the Director of Nursing (S1DON) confirmed that PRN orders for psychotropic medications should be limited to 14 days and require a prescriber evaluation before extension. The Consultant Pharmacist acknowledged the oversight, while the S1DON was unable to confirm whether hospice PRN medications were subject to the same 14-day limitation. This failure to adhere to the facility's policy resulted in the deficiency noted in the report.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status. Specifically, Resident #4, who was admitted to the facility and diagnosed with Major Depressive Disorder on 03/02/2024, had an inaccurate quarterly MDS assessment with an ARD of 03/14/2024. The diagnosis of Major Depressive Disorder was not coded as an active diagnosis in Section I of the MDS. During an interview, S2MDS, who is responsible for MDS assessments, confirmed that the diagnosis should have been accurately coded. S1DON also confirmed that the MDS should reflect all active diagnoses accurately.
Failure to Document Administered Narcotic Medication
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards and practices for one of the residents reviewed. Specifically, the facility did not ensure that an LPN documented the administration of narcotic medications on a resident's Medication Administration Record (MAR). The resident, who had diagnoses including Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking, was readmitted to the facility and required Morphine for pain management. On the specified date, the LPN removed Morphine from stock but did not document its administration on the MAR. During a phone interview, the LPN confirmed administering the medication but could not recall if it was documented. The Director of Nursing reviewed the MAR and confirmed that staff are expected to document any administered medication.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to designate a member of the interdisciplinary team to coordinate care with hospice representatives, as required by their policy. This deficiency was evidenced by the absence of up-to-date hospice binders for a resident who was readmitted to the facility and admitted to hospice services. Specifically, the hospice binder for the resident lacked the most recent hospice plan of care documents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that there was no designated staff member responsible for coordinating hospice care and that the hospice binder was incomplete.
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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