St James Place Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 333 Lee Drive, Baton Rouge, Louisiana 70808
- CMS Provider Number
- 195410
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at St James Place Nursing Care Center during CMS and state inspections, most recent first.
The facility failed to maintain accurate clinical records for three residents regarding physician-ordered baths/showers. Facility policy required CNAs to document ADL assistance every shift, including baths and showers. For multiple dates over a two-month period, bath logs lacked entries showing that ordered baths/showers were provided. CNAs later reported that at least some of these baths/showers were given but not documented, or could not recall whether care was provided and confirmed they had not charted it. The DON acknowledged that documentation of these baths/showers was missing from the residents’ records on the identified dates.
Ceiling vents in two kitchen areas were found covered with thick, fluffy gray debris above clean dish racks, with no documentation or clear responsibility for cleaning. Staff interviews confirmed the vents were not on a regular cleaning schedule, and 58 residents were potentially affected by meals prepared in these unsanitary conditions.
Nursing staff failed to accurately document a resident's pressure ulcer status, continuing to record the presence of a right heel wound after it had healed, despite clinical records and staff interviews confirming the wound's resolution. The inaccurate documentation persisted in weekly body audits, contrary to accepted professional standards.
A resident with mental health diagnoses was prescribed Risperidone, an antipsychotic, but the MDS assessment was inaccurately coded to indicate no antipsychotic use. Staff confirmed the error during interviews and acknowledged that MDS assessments should accurately reflect all medications received.
A resident receiving hospice care did not have the most recent Hospice Plan of Care in their Hospice Binder, as only an expired plan from a previous certification period was on file. The DON confirmed the absence of current documentation during review.
A resident with an indwelling catheter was observed on multiple occasions with the catheter bag and tubing resting on the floor, contrary to facility policy and the resident's care plan. Staff, including an LPN and the DON, confirmed that the catheter system should not touch the floor to prevent contamination, but this protocol was not followed.
A resident's record lacked documentation of education on pneumococcal and influenza vaccines, as well as the status of vaccine administration, refusal, or contraindication. The DON confirmed incomplete documentation and absence of evidence that the annual immunization process was followed for this resident.
A resident's medical record lacked documentation of COVID-19 vaccine education, consent, or declination, despite the vaccine being available and previously offered. The DON confirmed the absence of required records regarding vaccine education and status for the resident.
The facility failed to maintain accurate records for three residents regarding their bathing schedules. Despite the facility's policy requiring documentation of skilled services and ADL assistance every shift, records showed missing documentation for baths or showers on multiple dates. Interviews with CNAs confirmed that care was provided but not documented, and the DON acknowledged the lack of documentation.
The facility failed to notify the physician and family of significant changes in two residents' conditions. One resident experienced low blood glucose readings and changes in consciousness without physician notification, leading to an Immediate Jeopardy situation. Another resident's family was not informed of a critically low blood glucose reading.
The facility failed to ensure a diabetic resident received appropriate treatment according to the hypoglycemic protocol. Two LPNs did not follow standing orders for low blood glucose levels, did not notify the physician, and did not administer the correct treatment. The resident was found unresponsive and later without a pulse or breath sounds.
The facility failed to ensure that licensed nurses had the necessary competencies to manage hypoglycemia. An LPN did not follow the hypoglycemic protocol when a resident's blood glucose level was 49 mg/dL, and another LPN did not assess the resident's vital signs or notify the physician when the resident was found unresponsive with gurgled breathing. The resident was later found unresponsive, without a pulse or breath sounds.
The facility failed to post the required nurse staffing information on a daily basis at four nurse's stations. Observations revealed missing data on resident census, total number, and actual hours worked for RNs, LPNs, and CNAs on multiple dates. Interviews confirmed the responsible staff did not include the required data, and the administrator was unaware of the posting requirements.
The facility failed to respond to call lights in a timely manner for two residents, resulting in significant delays ranging from 36 to 121 minutes. One resident with Parkinson's Disease and another with a history of falls experienced these delays, which were confirmed by call light logs and resident interviews. The DON acknowledged the issue.
The facility failed to monitor side effects of anticoagulant medications for two residents. One resident with multiple diagnoses, including Metabolic Encephalopathy and Vascular Dementia, had no documentation of monitoring for Xarelto side effects. Another resident with bipolar disorder and a heart condition had no documentation of monitoring for Eliquis side effects. The DON confirmed the lack of monitoring.
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications by not ensuring appropriate diagnoses and adequate monitoring for two residents. The Director of Nursing confirmed the inappropriate indications and lack of monitoring documentation for the prescribed medications.
The facility failed to store food according to professional standards, affecting 49 residents. Observations revealed unlabeled and undated food items in various freezers and refrigerators, as well as expired canned goods in the walk-in pantry. Staff confirmed that all stored foods should be labeled, dated, and expired items removed, in accordance with the facility's policy.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or her responsible party. The resident's Medicare Part A Skilled Services episode started and ended within the specified dates, and the facility initiated the discharge before benefit days were exhausted. The DON confirmed that a NOMNC was never issued, despite it being required.
A resident with Dementia and other conditions requiring a Hoyer Lift with two staff members for transfers was independently transferred by a CNA without the lift device, contrary to the care plan and physician orders. Interviews with facility staff confirmed the prescribed transfer method was not followed, posing a risk to the resident's safety.
The facility failed to ensure that the oxygen tubing and humidifier bottle for a resident were properly labeled with the date of change, as required by facility policy and physician's orders. Staff confirmed that the equipment should have been labeled, but it was not, indicating a deficiency in the provision of respiratory care.
A hospice CNA was observed performing a bed bath on a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions. The facility lacked documented evidence of an Enhanced Barrier Precaution Policy, and the Director of Nursing confirmed that the observed practice was inappropriate.
Failure to Accurately Document Ordered Baths/Showers in Clinical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for three residents regarding ordered baths/showers, contrary to its own documentation policy and accepted professional standards. The facility’s policy, revised in October 2025, requires documentation every shift for skilled residents and for ADL assistance by CNAs, with records accurately reflecting nursing care and ADL assistance. For Resident #1, physician orders specified baths on Tuesday, Thursday, and Saturday during daytime hours, but the bath log from 12/11/2025 through 01/06/2026 showed no documentation of a bath or shower on multiple ordered dates, including 12/13/2025, 12/16/2025, 12/23/2025, 12/25/2025, and 01/06/2026. A CNA later confirmed that baths were provided on at least two of those dates but were not documented. For Resident #2, physician orders also required baths on Tuesday, Thursday, and Saturday during night hours, yet the bath log from 11/02/2025 through 01/03/2026 contained no documentation of baths or showers on numerous ordered dates. The CNA who worked with this resident on several of the missing dates recalled giving a shower on one of those dates but was unsure if it had been documented, and acknowledged that such care should be recorded. For Resident #3, with similar physician orders for daytime baths on Tuesday, Thursday, and Saturday, the bath log from 11/01/2025 through 01/07/2026 lacked documentation of baths or showers on several ordered dates. The CNA assigned on one of those dates could not remember if the bath was given and confirmed that she did not document it, though she should have. The DON verified that there was no documentation of completed baths or showers for these residents on the identified dates, despite the requirement that such care be recorded.
Failure to Maintain Sanitary Kitchen Ventilation
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not ensuring that ceiling vents in two kitchen locations were kept free of thick, fluffy gray debris. Observations revealed that the vent coverings above clean dish racks in both Kitchen A and Kitchen B were covered with excessive amounts of this substance, to the extent that the vent openings were obscured. Multiple staff members, including those responsible for kitchen sanitation and maintenance, were unaware of when the vents were last cleaned or who was responsible for their upkeep. There was no documentation available to indicate that the vents had been cleaned or maintained according to the facility's policy, which requires monthly cleaning and maintenance of ceiling tiles, vents, and lights. The deficiency had the potential to affect 58 residents who received meals prepared in the affected kitchens. Interviews with staff confirmed that the kitchen vents were not included in a regular cleaning or maintenance schedule, and there was no monitoring or documentation of cleaning or replacement of the vent coverings. The lack of adherence to established cleaning protocols and unclear assignment of responsibility contributed directly to the unsanitary conditions observed.
Inaccurate Documentation of Healed Pressure Ulcer
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records in accordance with accepted professional standards for one resident with a history of pressure ulcers. Specifically, nursing staff continued to document the presence of a right heel pressure ulcer in weekly body audits after the wound had been documented as healed. The clinical record showed that the right heel pressure ulcer, initially identified as Stage III, was resolved and wound care was discontinued, yet subsequent weekly body audits by nursing staff inaccurately described the wound as still present and requiring ongoing care. Interviews with facility staff confirmed the inaccuracy of the documentation. The Director of Nursing reviewed the resident's medical record and verified that the right heel pressure ulcer had healed, and any documentation after the healing date indicating the presence of the wound was incorrect. Additionally, a CNA stated that the resident no longer had any pressure injuries on his heels, further confirming the discrepancy between the resident's actual condition and the nursing documentation.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's medication status. A review of the clinical record for a resident admitted with diagnoses including bipolar disorder, depression, and anxiety showed that the annual MDS assessment indicated the resident was not receiving antipsychotic medication. However, physician orders documented that the resident was prescribed Risperidone, an antipsychotic, to be administered nightly. During interviews, facility staff confirmed that the MDS was inaccurately coded and acknowledged that all residents' MDS assessments should accurately reflect the medications they receive.
Failure to Maintain Current Hospice Plan of Care Documentation
Penalty
Summary
The facility failed to maintain an up-to-date system for ensuring that a resident's Hospice Binder contained the most recent Hospice Plan of Care. Specifically, for one resident who was admitted to the facility and receiving hospice services from a local agency, the only Plan of Care available in the Hospice Binder was from a previous certification period and had expired. During an interview, the Director of Nursing confirmed that the current Plan of Care was not present in the binder and acknowledged that it should have contained the most recent and up-to-date documentation.
Failure to Maintain Catheter Bag and Tubing Off Floor
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program as required by policy and resident care plans. Specifically, the facility did not ensure that a resident's indwelling catheter bag and tubing were kept off the floor, as observed on multiple occasions. The facility's policy and the resident's care plan both specified that catheter bags and tubing should not touch the floor to prevent contamination, yet observations on two separate days showed the catheter tubing and bag resting on the floor while the resident was in her room. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the catheter bag and tubing were found on the floor and acknowledged that this was not in accordance with facility policy or infection control standards. The resident involved had a physician's order for Foley catheter care every shift and a care plan approach to prevent the tubing or drainage system from touching the floor, but these measures were not followed during the observed periods.
Failure to Document Immunization Status and Education
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for immunizations had proper documentation regarding education on the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of whether the resident received, refused, or was medically contraindicated for these immunizations. Specifically, the clinical record for this resident did not contain any documentation of pneumococcal and influenza immunization status for the review period. During an interview, the Director of Nursing (DON) confirmed responsibility for the infection control program and acknowledged that the most recent vaccine consent form for the resident was dated several months prior to the review period. The DON also confirmed that there was no evidence that the annual immunization process was followed for this resident, and that documentation of consent, education, and vaccine administration was incomplete.
Failure to Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for one of five residents whose records were reviewed for immunization compliance. Specifically, the medical record for a resident admitted in 2024 did not contain documentation that the resident or their representative received education about the benefits and potential side effects of the COVID-19 vaccine. Additionally, there was no record indicating whether the resident received the COVID-19 vaccine, declined it, or had a medical contraindication. The Director of Nursing confirmed that while COVID-19 vaccines were available and the resident had been offered the vaccine in the previous year, there was no documentation of education, consent, or declination in the resident's file for 2024. This lack of documentation was identified through interviews and record review, and had the potential to affect all residents requiring immunization education and consent.
Failure to Document Resident Bathing Care
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards for three residents regarding their bathing schedules. The facility's policy requires documentation of skilled services and assistance with activities of daily living (ADL) every shift. However, the clinical records for three residents showed missing documentation for baths or showers on multiple dates in September 2024. Interviews with CNAs revealed that baths and showers were provided on these dates, but the care was not documented as required. Resident #1's care plan indicated they should be offered a bath of choice at least three days a week, but there was no documentation for several dates. Similarly, Resident #2's care plan also required a bath of choice at least three days a week, yet documentation was missing for multiple dates, including a refusal that was not recorded. Resident #3's care plan had the same requirement, with missing documentation for several dates. The Director of Nursing confirmed the lack of documentation for these residents, acknowledging that it should have been recorded.
Failure to Notify Physician and Family of Significant Changes
Penalty
Summary
The facility failed to ensure nursing staff communicated significant changes in status to the resident's physician or family for two residents. For Resident #48, the nursing staff did not notify the physician after obtaining low blood glucose readings, noting a change in breath sounds, or observing a change in the level of consciousness. Specifically, an LPN administered sugar water to Resident #48 after a blood glucose reading of 49 mg/dL but did not notify the physician. Later, another LPN found Resident #48 unresponsive with gurgled breathing and still did not notify the physician or assess vital signs. Resident #48 was eventually found unresponsive without a pulse or breath sounds. For Resident #46, the nursing staff failed to notify the resident's family after a low blood glucose reading of 24 mg/dL was obtained. The responsible party for Resident #46 confirmed that they were not notified of the low blood sugar event. The DON stated that family should be notified of low blood sugar levels once treatment was provided and the blood sugar was stable, but this protocol was not followed. These deficiencies resulted in an Immediate Jeopardy situation for Resident #48, which was later removed after the facility implemented an acceptable Plan of Removal. However, the deficient practice continued to pose more than minimal harm to the remaining residents in the facility.
Failure to Implement Hypoglycemic Protocol for Diabetic Resident
Penalty
Summary
The facility failed to ensure a resident received treatment and care according to the resident's plan of care and physician's orders. Specifically, two LPNs did not implement the hypoglycemic protocol for a diabetic resident whose blood glucose level was critically low. One LPN administered sugar water instead of following the standing orders, and did not notify the physician of the low readings. The resident's blood glucose level remained low, and the LPN did not recheck it as planned. The second LPN found the resident unresponsive with gurgled breathing but did not assess vital signs or notify the physician, leading to the resident being found unresponsive without a pulse or breath sounds shortly thereafter. The resident involved had a diagnosis of Type 2 Diabetes Mellitus and was at risk for unstable blood sugar levels. The facility's policy required monitoring blood sugar levels as ordered by the physician and notifying the physician of any changes in condition. The hypoglycemic protocol included steps to verify low blood glucose readings, treat them according to specific guidelines, and notify the physician. However, these steps were not followed by the LPNs involved. Interviews with the LPNs and the Director of Nursing confirmed that the hypoglycemic protocol was not followed. The LPNs did not administer the appropriate treatment, such as juice or glucagon, and failed to notify the physician of the resident's condition. The Director of Nursing stated that the hypoglycemic protocol was the standing doctor's orders for diabetic residents and should have been followed. The physician also confirmed that the nurse should have called the on-call physician immediately when the resident's blood glucose reading was critically low.
Failure to Implement Hypoglycemic Protocol
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to care for a resident's needs, specifically in managing hypoglycemia. On the date of the incident, an LPN failed to implement the hypoglycemic protocol when a resident's blood glucose level was 49 mg/dL. Instead of following the protocol, the LPN administered approximately 2 ounces of sugar water via oral swab and did not notify the physician of the low readings. The resident's blood glucose level only increased to 53 mg/dL, and the LPN did not take further appropriate actions or notify the physician as required by the protocol. Another LPN observed the same resident later and found the resident unresponsive with gurgled breathing. Despite these critical signs, the LPN did not assess the resident's vital signs or blood glucose levels and failed to notify the physician. The resident was later found unresponsive, without a pulse or breath sounds. Interviews with the involved staff revealed a lack of knowledge and adherence to the hypoglycemic protocol and the necessity of notifying the physician in such situations. The facility's policies clearly outlined the steps to be taken in the event of hypoglycemia, including verifying blood glucose results, treating according to the protocol, and notifying the physician. However, the involved LPNs did not follow these guidelines, leading to the resident's deteriorating condition and eventual unresponsiveness. The Director of Nursing confirmed that the hypoglycemic protocol was part of the standing doctor's orders and should have been followed by the nursing staff.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis at four nurse's stations. Observations at Nursing Stations a, b, c, and d revealed that the posted staffing data did not include the resident census, the total number, and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on multiple dates and times. Specific observations were made on 05/28/2024 and 05/29/2024, showing the absence of this critical information at various times throughout the day. Interviews conducted on 05/31/2024 with S8SD and S1ADM confirmed the deficiency. S8SD, who was responsible for posting the staffing assignment sheet, admitted that she did not include the required data. S1ADM, the facility administrator, stated that he was not aware of the specific data that needed to be posted. This lack of awareness and failure to include essential staffing information led to the deficiency noted in the report.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure residents received services with reasonable accommodation of their needs and preferences by not responding to call lights in an appropriate time frame. Resident #27, who has diagnoses including Parkinson's Disease, Muscle Weakness, and Unsteadiness on Feet, experienced significant delays in call light responses, ranging from 37 to 78 minutes. The resident, who has intact cognition, reported waiting up to an hour for a response several times a day. This was confirmed by the call light log and an interview with the resident on 05/28/2024. Similarly, Resident #33, who has diagnoses including Repeated Falls, Personal History of TIA, and CVA, also experienced prolonged call light response times, ranging from 36 to 121 minutes. The resident, who has moderate cognitive impairment, reported waiting more than 30 minutes for a response. The call light log and an interview with the resident on 05/28/2024 confirmed these delays. The Director of Nursing (S2DON) acknowledged that the call light response times were not appropriate and confirmed the findings.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for side effects with the use of anticoagulant medication for two residents. Resident #32, who was admitted with diagnoses including Metabolic Encephalopathy, Cognitive Communication Deficit, Type 2 Diabetes, Vascular Dementia, and Chronic Embolism, had an order for Xarelto 15 mg at dinner for acute embolism. There was no documentation of monitoring for anticoagulant side effects for this resident. Similarly, Resident #250, admitted with diagnoses including bipolar disorder and a heart condition, had an order for Eliquis 5 mg by mouth twice daily for unspecified atrial fibrillation. There was no documentation of monitoring for side effects of Eliquis for this resident. The Director of Nursing confirmed the lack of documentation for both residents and acknowledged that monitoring should have been completed every shift.
Failure to Ensure Appropriate Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications. Specifically, the facility did not ensure that antipsychotic medications were used only when there was an acceptable diagnosis and did not adequately monitor the effectiveness and side effects of psychotropic medications for two residents. Resident #32 was prescribed Clonazepam for Radiculopathy, Quetiapine for Vascular Dementia, and Viibryd for a Depressive Episode. However, there was no documentation of monitoring for target behaviors or side effects of these medications since they were started. Similarly, Resident #250 was prescribed Fluoxetine for Depressive Disorder, Clonazepam for Spondylosis, and Risperdal for Spondylosis, with no documentation of monitoring for target behaviors or side effects provided by the facility. The Director of Nursing confirmed that the diagnoses for which these medications were prescribed were not appropriate indications and acknowledged the lack of monitoring documentation for both residents. An interview with the Director of Nursing revealed that Vascular Dementia was not an appropriate indication for the use of Quetiapine, and Radiculopathy and Spondylosis were not appropriate indications for the use of Clonazepam and Risperdal. The facility failed to provide documentation of monitoring for target behaviors or side effects for the psychotropic medications prescribed to Resident #32 and Resident #250. This lack of appropriate diagnosis and monitoring constitutes a failure to ensure that residents' drug regimens were free from unnecessary psychotropic medications, as required by regulations.
Failure to Store Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, affecting the 49 residents who were served meals from the kitchen. Observations in Kitchen A revealed five unsealed sausage patties, two uncooked hamburger patties, two pieces of uncooked chicken, two small Styrofoam containers of scooped orange sherbet, and five small glass containers of scooped vanilla ice cream, all unlabeled and not dated in Freezers C and D. Additionally, three bunches of discolored lettuce, two small Styrofoam containers of melted cheese, and two small quart-size containers of tuna salad were found unlabeled and not dated in Refrigerator E. In Kitchen B, five cans of cream of mushroom soup and twenty-three cans of tomato juice were found with expired dates in the walk-in pantry. The main kitchen also had an opened, undated gallon container of salad dressing in the walk-in cooler. Interviews with staff confirmed the findings. S6ESC and S7KM both stated that all stored foods should be labeled and dated once opened, and food with an expired date should be removed and not available for consumption. S1ADM also confirmed that all stored food should be labeled and dated, and food with an expired date should be discarded. The facility's undated policy titled Food Receiving and Storage Policy was reviewed, which stated that all items should be dated and labeled with a received date, and opened items should be dated with an opening date and a use-by date of no more than three days from the opening date. The policy also required the removal of any product that has been opened longer than three days or is past the expiration date.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or her responsible party. This deficiency was identified during a review of the SNF Beneficiary Notification Review Form for a resident whose Medicare Part A Skilled Services episode started on 02/08/2024 and ended on 02/28/2024. The facility initiated the discharge from Medicare Part A Services before benefit days were exhausted. An interview with the Director of Nursing (DON) confirmed that a NOMNC was never issued to the resident or her responsible party, despite it being required.
Failure to Use Hoyer Lift for Resident Transfers
Penalty
Summary
The facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents by not utilizing a Hoyer Lift with the assistance of two staff members for transfers. Resident #28, who had diagnoses including Dementia, Generalized Muscle Weakness, Other Lack of Coordination, and Abnormal Posture, was observed being transferred independently by a CNA without any lift device, despite her care plan and physician orders specifying the need for a Hoyer Lift with two staff members. The CNA confirmed she had never used a Hoyer Lift for Resident #28 and had transferred her independently multiple times, contrary to the care plan and physician orders. Interviews with the LPN, RTD, and DON confirmed that Resident #28 was assessed to need a Hoyer Lift for transfers and that staff should always use the Hoyer Lift with two staff members for her transfers. The facility had clear protocols and care plans in place, but these were not followed by the CNA, leading to the deficiency. The failure to adhere to the prescribed transfer method posed a risk to Resident #28's safety and well-being.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. Specifically, the facility did not ensure that the oxygen tubing and humidifier bottle for Resident #21 were properly labeled with the date of change. Resident #21, who had diagnoses including Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation, Heart Failure, and Obstructive Sleep Apnea, was observed using an oxygen nasal cannula with a humidifier. However, the oxygen tubing and humidification bottle were not labeled with a date indicating when they were last changed, contrary to the facility's policy and physician's orders which required weekly changes and labeling on Sundays. Interviews with staff members, including an LPN and the Director of Nursing (DON), confirmed that the oxygen tubing and humidification bottle should have been labeled with the date of change. The LPN acknowledged that Resident #21's equipment was not labeled as required, and the DON confirmed that all oxygen tubing and humidifiers should be changed weekly and labeled with the date of change. The facility's failure to adhere to these protocols was identified during the survey, highlighting a deficiency in the provision of respiratory care for Resident #21.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure a Certified Nursing Assistant (CNA) used Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions during a bed bath. Specifically, a hospice CNA was observed performing a bed bath on a resident without wearing a gown, despite the resident having a physician's order for Enhanced Barrier Precautions. The Enhanced Barrier Precaution sign on the resident's door indicated that a gown and gloves should be worn during high-contact activities such as bathing. The facility also lacked documented evidence of an Enhanced Barrier Precaution Policy. The Director of Nursing confirmed that all staff, including hospice staff, should wear a gown and gloves when providing care to residents on Enhanced Barrier Precautions and acknowledged that the observed practice was inappropriate.
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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