St Jude's Health & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 450a S Claiborne Ave, Fl 6, New Orleans, Louisiana 70112
- CMS Provider Number
- 195517
- Inspections on file
- 28
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 16 (2 serious)
Citation history
Health deficiencies cited at St Jude's Health & Wellness Center during CMS and state inspections, most recent first.
An LPN physically and verbally abused a resident who was moderately cognitively intact, repeatedly striking the resident’s face, head, shoulders, arms, and chin, kneeling on the resident’s neck, attempting to drag the resident by his shirt across the floor, and yelling profanities such as “b***h, don’t hit me” and “b***h, I’m tired of you” in the presence of staff and another cognitively intact resident. Two CNAs witnessed the abuse, briefly intervened to pull the LPN off when it appeared the resident could not breathe, but did not immediately report the incident to the Administrator or ensure the LPN was removed from resident contact; instead, they left the unit for several minutes to seek assistance, leaving the LPN alone with the abused resident and about 20 other residents, and later only intermittently monitored the situation while completing rounds. The Administrator and DON later acknowledged that the LPN should not have been left alone with residents after the abuse and that the abuse should not have occurred.
The facility failed to ensure that witnessed physical and verbal abuse of a resident by an LPN was reported to the administrator and state agency within the required 2-hour timeframe. An LPN repeatedly struck a resident’s face, head, and shoulders with a closed fist, placed her knee on the resident’s neck, attempted to drag the resident by his shirt, and yelled profanities at the resident in front of staff and another resident. The LPN also directed CNAs not to assist the resident from the floor or from his chair, and the CNAs left the unit for several minutes and later left the LPN unmonitored with access to all residents. Despite facility policies requiring immediate reporting of suspected or actual abuse, the CNAs who witnessed or were informed of the abuse did not notify administrative staff until the following day, and the administrator acknowledged the incident was not reported to the state agency within the mandated timeframe.
A cognitively intact resident, identified on the facility’s smoker list as an unsafe smoker, was denied the ability to smoke during nighttime hours because they were not on the facility’s safe smoker list, despite a policy stating residents have the right to smoke and that cognitively impaired or mobility-limited residents may smoke with staff supervision. The resident reported being refused nighttime smoking, an LPN confirmed the resident was not on the list allowing smoking after extended hours, and reception staff stated that unsafe smokers were not permitted to go outside at night and acknowledged they had previously denied this resident’s requests to smoke during those hours, contrary to the DON’s description of how unsafe smokers should be supervised.
A resident with moderate cognitive impairment was found with medications left unsecured at the bedside, contrary to the facility’s medication storage policy requiring locked compartments and restricted access to drugs. Surveyors observed a split white pill on the floor next to a labeled medication cup and another labeled cup containing a pill on the bedside table. An LPN confirmed the medications had been left in the room, acknowledged the resident did not have the capacity to self-administer medications, and stated they should not have been left at the bedside; the DON also acknowledged that the medications were improperly left in unlocked, unattended cups.
A resident with stage 4 CKD had a physician-ordered renal diet specifying no potatoes, which was reflected on the meal ticket. However, the resident was observed being served cubed potatoes. An LPN acknowledged this conflicted with the renal diet, and the DON explained that the process requires dietary staff to follow the meal ticket and floor staff to verify trays against diet orders, confirming the resident should not have received potatoes.
Staff failed to follow hand hygiene and glove-change requirements during incontinence care for a resident. Two CNAs removed a soiled brief, cleansed the buttocks and perineal area, and then proceeded to apply a clean brief, reposition the resident, place a clean draw sheet, and handle clean linens and room furnishings without changing gloves or performing hand hygiene, despite facility policy and CDC guidelines requiring hand decontamination when moving from contaminated to clean body sites. Both CNAs later acknowledged they should have changed gloves and performed hand hygiene, and the DON confirmed this expectation.
The facility did not administer influenza and pneumococcal vaccines to a resident despite signed consents from the responsible party and a facility policy requiring vaccination unless contraindicated or refused. The resident, who had moderately impaired cognition, expressed a desire to receive both vaccines, and the responsible party confirmed consent had been given. Review of the clinical record showed no documentation of vaccine administration, and the ADON/Infection Preventionist, DON, and Administrator all acknowledged there was no evidence the vaccines had been provided.
A resident was physically struck in the face by another resident in the day room, with the incident witnessed by two CNAs and later confirmed by those involved. The facility's investigation substantiated that resident-to-resident abuse occurred, reflecting a failure to protect residents from physical mistreatment as required by policy.
A resident in an LTC facility was hospitalized with valproic acid toxicity after the facility failed to conduct a timely lab test as ordered by the resident's nurse practitioner. The resident, on Depakote for dementia and anxiety, showed signs of lethargy and unresponsiveness, leading to their transfer to the hospital. The facility's DON acknowledged the oversight, and the consulting pharmacist highlighted the importance of monitoring valproic acid levels.
A resident was hospitalized with valproic acid toxicity after the facility failed to implement a physician's lab order for a valproic acid level. The DON was responsible for ensuring lab orders were carried out but could not explain the oversight. The COO identified problems from grievances and surveys, but the deficiency was not addressed in time. The CEO did not initially recognize the situation as Immediate Jeopardy, and no additional documentation was provided to dispute the findings.
A facility failed to maintain a safe and clean environment for a resident, as maintenance did not cover a wall socket and housekeeping did not clean an unknown brown substance from the floor. These issues were confirmed by the COO during observations.
A facility failed to provide timely incontinence care for a resident who required substantial assistance for toileting and personal hygiene. The resident was found with a bowel movement leaking from the adult brief onto the abdomen, incontinent pad, and bed sheets, indicating a lapse in care. The CNA last checked the resident at 3 AM, not adhering to the 2-hour check requirement. The DON confirmed the resident should be checked every 2 hours.
A facility failed to ensure staff used proper PPE for a resident on EBP. A CNA entered a resident's room without a gown and emptied the urinary catheter, contrary to policy. The CNA was unaware of the requirement, and both the DON and Infection Preventionist confirmed the need for gowns during such procedures.
The facility restricted resident visitation to between 8:00 AM and 8:00 PM, requiring exceptions to be approved by the Administrator or DON, without documented clinical or safety reasons. Interviews with a resident and staff confirmed the enforcement of these restricted hours, despite the Administrator's acknowledgment that residents should have unrestricted visitation.
A facility failed to provide adequate dialysis care for a resident by not assessing the dialysis access site or obtaining vital signs upon return from dialysis. There was also a lack of communication with the dialysis center regarding the resident's condition. Interviews confirmed these deficiencies, with staff acknowledging the failure to follow the facility's process for dialysis care documentation.
The facility failed to properly label and dispose of insulin pens, resulting in a deficiency. An observation of a medication cart revealed that several insulin pens were either not labeled with the date they were opened or were available for use beyond the recommended period. An LPN and the DON confirmed that the facility's policy required insulin to be discarded 28 days after opening, and the medications in question had been opened over 30 days ago.
A resident's right to smoke was restricted by the facility's policy, which only allowed smoking between 7:00AM and 7:00PM. Despite being identified as a safe smoker and cognitively intact, the resident was not permitted to smoke outside these hours, as confirmed by interviews with staff, including the Smoking Aide and Administrator.
A facility failed to ensure a resident's code status was consistent across medical records. The resident's chart indicated a Full Code status, while the EMR and physician's orders showed a DNR status. Interviews with an LPN and the DON confirmed the discrepancy, which could lead to inappropriate medical interventions.
The facility failed to provide and explain the required Medicare Non-Coverage Notices to three residents before terminating their Medicare Part A services. The NOMNC forms were not documented as given or signed, and the SNFABN forms were signed without explanation. One resident had severe cognitive impairment, highlighting the need for proper communication with responsible parties.
The facility failed to accurately assess the dental status of two residents upon admission. One resident with moderate cognitive impairment and another with intact cognition were both reported to have no dental issues, despite observations and interviews confirming missing teeth. The facility administrator could not explain the discrepancies in the MDS assessments.
A facility failed to maintain a resident's Level II PASARR documentation in their medical record. The resident, admitted with Schizophrenia, Bipolar Disorder, and Unspecified Dementia, lacked the necessary documentation completed by the Office of Behavioral Health. Staff acknowledged the oversight during interviews.
A facility failed to supervise a resident identified as an unsafe smoker. The resident, with severe cognitive impairment and listed on the Unsafe Smoker List, was observed smoking without direct supervision. The smoking aide was seated away from the resident, who received a cigarette and had it lit by other residents. Staff confirmed the need for direct supervision, which was not provided, leading to a deficiency in care.
A facility failed to limit a resident's PRN order for Lorazepam, a psychotropic medication, to 14 days or provide a clinical rationale for its continuation. The order lacked documentation of a specified duration or physician's rationale, as acknowledged by the DON.
A resident's CBC was not completed as ordered due to the lab's inability to obtain a specimen, and the physician was not notified. The facility lacked documentation of the physician's notification, as confirmed by the DON.
Two residents in the facility were not provided with necessary dental services, despite both expressing a desire to see a dentist and obtain dentures. Observations revealed that both residents were missing several teeth, and there was no documented evidence of dental evaluations since their admission. The facility's dental treatment schedule did not include these residents, and interviews with staff confirmed the lack of evaluation without providing a reason.
The facility's dumpster was observed to be missing a lid and open to the air, with loose trash on the ground around it. The Dietary Manager and Administrator acknowledged the issue, confirming that the dumpster and its surrounding area were not maintained in a sanitary manner.
The facility did not involve direct care staff, residents, or their representatives in the development of its facility-wide assessment. There was no documented evidence of participation from an LPN, a CNA, a resident, or a resident representative, as confirmed by the administrator.
The facility failed to administer the pneumococcal vaccine to two residents who had signed consents for the vaccination. Despite the consents, there was no documented evidence that the vaccines were administered or medically contraindicated. Interviews with the administrator confirmed the lack of documentation, highlighting a deficiency in the facility's vaccination process.
The facility failed to administer the COVID-19 vaccine to a resident despite having obtained consent from the responsible party. There was no documentation to indicate that the vaccine was given or that it was medically contraindicated. The administrator confirmed the absence of such documentation.
The facility failed to implement and review individualized fall prevention interventions for three residents who experienced multiple falls. Despite policies requiring new interventions after each fall, there was no documented evidence of these interventions being implemented or reviewed for effectiveness. Interviews with staff confirmed the lack of documentation and communication regarding updates to the residents' care plans.
The facility failed to maintain a sanitary environment for two residents. One resident's room had a brown smear on the wall, while another resident's room and bathroom were found with multiple unsanitary conditions, including a dirty isolation cart, brown substances on surfaces, and cluttered bedside tables. Interviews with staff confirmed these conditions, and the resident expressed dissatisfaction with the cleanliness.
A resident in an LTC facility was found with a dislocated hip, but the facility failed to conduct a thorough investigation. The investigation lacked statements from all relevant staff, including LPNs and CNAs who observed the resident's condition. The Director of Nursing and Administrator did not obtain comprehensive documentation, leading to an incomplete understanding of the incident.
A resident with severely impaired cognition experienced a decline in ADLs and multiple falls, including a hip fracture from a wheelchair fall. The facility failed to update the care plan to address these changes, as confirmed by the administrator.
A CNA was observed asleep while on duty, failing to provide care to seven residents during a day shift. The CNA had signed the facility's Employee Code of Conduct, which prohibits sleeping on duty. The incident was confirmed by the DON and the facility's Administrator.
The facility failed to ensure that nurse aides were trained and competent, allowing uncertified staff to work independently and provide direct care to residents. This deficiency was identified for eight staff members, including direct service workers and a front desk receptionist, who were not enrolled in or scheduled for any CNA certification courses. The facility's policy required qualified nursing staff, but uncertified staff were assigned to work independently, putting all 79 residents at risk.
The facility failed to ensure that staff working as nurse aides met the minimum state-approved competency and training requirements. This resulted in an Immediate Jeopardy situation when unqualified staff were allowed to work independently, providing direct care to residents without the necessary certification or training. The deficiency was confirmed through observations, interviews, and record reviews.
Failure to Protect Resident From Physical and Verbal Abuse and to Immediately Remove Abusive LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a staff member and to immediately remove the alleged perpetrator from resident contact after the abuse was witnessed. On the date of the incident at approximately 4:00 PM, an LPN physically and verbally abused a resident identified as moderately cognitively intact, with a BIMS score of 12 on a recent MDS. The LPN hit the resident repeatedly on the face, head, shoulders, arms, and chin area with a closed fist, placed her knee on the resident’s neck to pin him down, grasped his shirt and attempted to drag him across the floor, and yelled profanities at him, including “b***h, don’t hit me,” “b***h, don’t touch me,” “b***h I’m tired of you,” and “b***h get off of me.” This conduct was directly witnessed by two CNAs and another resident, who was cognitively intact with a BIMS score of 15. During the incident, one CNA intervened by getting the resident to release the LPN and give her his hands, after which the LPN initially got up as if to walk away, then turned back, put her knee on the resident’s neck, and continued to strike him. The CNAs reported that it appeared the resident could not breathe with the LPN kneeling on his neck, prompting them to pull the LPN off the resident. The LPN then walked away, returned, and again attempted to drag the resident by his shirt on the floor. Throughout this time, the LPN continued to verbally abuse the resident and instructed the CNAs, in the resident’s presence, to “leave that b***h on the floor, don’t help him up.” Later, around 5:00 PM, when one CNA was preparing to make rounds, the LPN again verbally abused the resident by instructing the CNA, in front of the resident, to “leave that b***h in his chair.” The resident later stated in an interview that the LPN had previously hit him. Despite witnessing the physical and verbal abuse, the CNAs did not immediately report the incident to the Administrator or remove the LPN from resident contact. Instead, both CNAs left the floor for approximately eight minutes to find assistance to get the resident off the floor, leaving the LPN alone with the abused resident and approximately 20 other residents on that floor. One CNA stated she was in shock and did not know what to do, and the other CNA indicated that at the time of the incident she did not know who to report abuse to. During the period from approximately 5:00 PM to 6:00 PM, one CNA only periodically visualized the resident and the LPN while completing rounds and did not constantly monitor them, leaving the LPN with ongoing access to the resident and other residents. Facility leadership, including the Administrator and DON, later acknowledged that the LPN should not have been left alone with residents after the abuse occurred and that the physical and verbal abuse should not have happened.
Removal Plan
- S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.
- S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.
- S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement.
- Staff performed an assessment of Resident #1 for any injuries and/or pain.
- S1Administrator entered a report regarding the physical and verbal abuse in the State Incident Management System (SIMS).
- Resident #1's medical provider conducted a psychological evaluation on Resident #1.
- S1Administrator had staff do an audit of the other residents that resided on Floor b to determine if they have suffered any abuse.
- S1Administrator obtained a witness statement from Resident #2.
- S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator.
- S1Administrator reported the physical and verbal abuse to the local police department.
- S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners.
Failure to Timely Report Witnessed Physical and Verbal Abuse by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that witnessed physical and verbal abuse of a resident was reported to the administrator/designee and the state agency within the required 2-hour timeframe. On 02/17/2026 at approximately 4:00 PM, an LPN physically and verbally abused Resident #1 by repeatedly hitting him on the face, head, and shoulders with a closed fist, placing her knee on his neck, grasping his shirt and attempting to drag him across the floor, and yelling profanities at him, including, “b***h, don’t hit me” and “b***h, I’m tired of you.” This abuse was witnessed by two CNAs (S5 and S6) and another resident (Resident #2). The LPN further stated to the two CNAs, in front of Resident #1, “leave that b***h on the floor, don’t help him up.” The immediate jeopardy situation continued when the two CNAs left Floor B for approximately 8 minutes, leaving Resident #1 and 20 other residents alone on the unit with the same LPN who had just committed the physical and verbal abuse. Later, at approximately 5:00 PM, the LPN instructed one of the CNAs, again in front of Resident #1, to “leave that b***h in his chair.” The CNA then left the LPN unmonitored and with access to all 21 residents on Floor B while she went in and out of rooms to complete her rounds. Despite witnessing the abuse and understanding that abuse should be reported immediately, the CNAs did not report the incident to the administrator or other administrative staff within 2 hours, and the LPN remained on duty until she clocked out at 11:20 PM. Multiple staff interviews confirmed that the abuse was not reported in a timely manner and that there was confusion or lack of knowledge among some staff about how to contact administrative staff when they were not physically present in the facility. S5CNA acknowledged she did not report the abuse to any administrative staff or nurses until the morning of 02/18/2026 and stated she did not know how to reach them at the time of the incident. S6CNA similarly indicated that the abuse should have been reported immediately but was not reported until the next day, and that she did not know who to report to at the time. Another CNA (S7) reported that S5CNA told her about the abuse on 02/17/2026, but she also did not report it, despite having the phone numbers of the administrator and DON. The administrator and DON both indicated that the CNAs who witnessed or knew of the abuse should have reported it immediately. The administrator acknowledged that the physical and verbal abuse should have been reported to the state agency within 2 hours, which did not occur. The facility’s abuse-related policies, including the Abuse Prevention policy, Abuse Recognition, Reporting, and Investigation policy, and Abuse Reporting and Investigation policy, required that any person who witnessed or suspected abuse immediately inform the house supervisor, who would notify the administrator or designee, and that the administrator or designee report all allegations of suspected or actual abuse through the state incident reporting system and to proper parties as required by state and federal law. Despite these policies, the witnessed abuse of Resident #1 by the LPN on 02/17/2026 was not reported to the administrator until approximately 10:30 AM on 02/18/2026, and thus was not reported to the state agency within the required 2-hour timeframe. This failure to follow established reporting procedures and to promptly notify the appropriate authorities constituted the cited deficiency.
Removal Plan
- S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.
- S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.
- S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement.
- S1Administrator had staff perform an assessment of Resident #1 for any injuries and/or pain.
- S1Administrator entered a report regarding the physical and verbal abuse in the State Incident Management System (SIMS).
- Resident #1's medical provider conducted a psychological evaluation on Resident #1.
- S1Administrator had staff do an audit of the other residents that resided on Floor b to determine if they have suffered any abuse.
- S1Administrator obtained a witness statement from Resident #2.
- S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator.
- S1Administrator reported the physical and verbal abuse to the local police department.
- S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners.
Failure to Honor Resident’s Right to Smoke per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to smoke in accordance with its own Resident Smoking and Tobacco Use Policy. The policy, effective 08/01/2025, stated that residents had the right to smoke, and that residents who were cognitively impaired or had mobility limitations could only smoke under staff supervision, with staff responsible for monitoring compliance. Resident #6’s Quarterly Minimum Data Set dated 12/26/2025 showed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Despite this, the facility’s undated list of smokers identified Resident #6 as an unsafe smoker. Resident #6 reported on 01/22/2026 that he was not allowed to go outside to smoke at night because he was not on the list permitting smoking after 7:00 PM. An LPN confirmed that Resident #6 was not on the list of smokers allowed to smoke past the extended hours of 7:00 AM to 8:00 PM. The DON stated that the security guard, evening receptionist, and/or night receptionist were responsible for supervising unsafe smokers who wanted to smoke outside the 7:00 AM to 7:00 PM timeframe. However, two receptionists reported that unsafe smokers were not allowed to go outside to smoke at night and that only residents on the safe smoker list could go out during those hours. Both receptionists acknowledged they had previously refused Resident #6 the ability to smoke at night because he was not on the safe smoker list, resulting in the resident being denied the right to smoke during nighttime hours.
Medications Left Unsecured at Bedside of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments and accessible only to authorized personnel, resulting in a resident having medications left at the bedside. The facility’s undated Storage of Medications policy stated that medications were to be stored in locked compartments, in their original packaging, and that only persons authorized to prepare and administer medications should have access to them. Review of a quarterly MDS for Resident #47, with an Assessment Reference Date of 10/29/2025, showed a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. During observation of Resident #47’s room on 01/21/2026 at 12:40 PM, surveyors noted a white pill on the floor split in two next to a medication cup labeled with Resident #47’s name, and a second medication cup, also labeled with the resident’s name, containing a white pill on the bedside table. In interviews, the LPN confirmed the pills and medication cups were in the resident’s room, stated that the medications should not have been left at the bedside, and reported that the resident did not have the mental capacity to self-administer medications; the DON also acknowledged that the medications should not have been left at the bedside in unlocked, unattended medication cups. These observations and interviews demonstrate that the facility did not follow its own medication storage policy and allowed a moderately cognitively impaired resident unsupervised access to medications in the room, contrary to requirements that only authorized staff have access to drugs and biologicals and that such items be stored in locked compartments.
Failure to Follow Renal Diet Restrictions for Resident with CKD
Penalty
Summary
The facility failed to provide a diet that met a resident's special dietary needs when a resident with a physician-ordered renal diet was served food inconsistent with that order. The facility's undated Nutrition policy stated that all physician-ordered diets were to be implemented promptly and that the dietary department was to prepare and serve meals that met ordered diets and nutritional requirements. The resident's medical record showed a diagnosis of stage 4 chronic kidney disease, and the January 2026 physician's orders specified a renal diet. The resident's meal ticket for 01/21/2026 further specified a renal diet with no potatoes. Despite these orders and documentation, observation on 01/21/2026 at 1:05 PM showed the resident was served cubed potatoes. An LPN immediately acknowledged that the resident should not have been served potatoes per the renal diet. The DON described the facility's process for ensuring correct diets, stating that diet recommendations are placed on the meal ticket, dietary aides are to follow the meal ticket when preparing plates, and floor staff are to check trays against the meal ticket when distributing them, notifying nursing and dietary if inconsistencies are found. The DON confirmed that the resident should not have been served potatoes.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during incontinence care. The facility’s Standard Precautions policy required staff to perform hand hygiene immediately after contact with any resident item that may be contaminated, and CDC guidelines required hand decontamination when moving from a contaminated body site to a clean body site during patient care. During an observation, two CNAs entered a resident’s room to perform incontinence care, removed the resident’s soiled diaper, and wiped the resident’s buttocks and perineal area. After completing care of the contaminated area, the CNAs did not change their gloves or perform hand hygiene before proceeding to place a clean diaper on the resident, roll and reposition the resident, place a clean draw sheet, and cover the resident with clean linen. One CNA then opened and closed the resident’s dresser door and raised the head of the bed while still wearing the contaminated gloves, without performing hand hygiene or changing gloves. In subsequent interviews, both CNAs acknowledged they had not changed gloves or performed hand hygiene after removing the soiled diaper and stated they should have done so. The DON confirmed that the CNAs should have changed gloves and performed hand hygiene when moving from a contaminated body area to a clean body area during incontinence care.
Failure to Administer Influenza and Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were administered in accordance with its own policy for one resident. The facility’s undated Influenza and Pneumococcal Vaccine policy stated that residents should be vaccinated against pneumococcal disease and influenza unless medically contraindicated or refused by the resident or legal representative. Resident #60’s Minimum Data Set, with an Assessment Reference Date of 01/07/2026, showed the resident was admitted on 07/02/2025 and had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. Review of the clinical record on 01/20/2026 revealed no documented evidence that the resident had received either the influenza or pneumococcal vaccines. Further record review showed that on 07/02/2025, the resident’s responsible party had signed consent forms for both the pneumococcal and influenza vaccines. In an interview, the resident stated he wanted the influenza and pneumococcal vaccines but had not received them, and the responsible party confirmed she had consented for the vaccines and was unsure if they had been given. The Assistant DON/Infection Preventionist reported that the facility had no evidence the resident received either vaccine since admission. The DON and the Administrator both acknowledged in interviews that the resident had not received the influenza or pneumococcal vaccinations prior to 01/21/2026 and that the resident should have received them.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its own Abuse Recognition, Reporting, and Investigation policy. On the morning of 09/10/2025, one resident entered the day room and struck another resident in the face, an incident witnessed by two CNAs. The physical altercation was later confirmed by both the resident who committed the act and the staff who observed it. The facility's investigation substantiated that resident-to-resident abuse had occurred, indicating a failure to prevent physical mistreatment as outlined in facility policy.
Failure to Conduct Timely Lab Test Leads to Hospitalization
Penalty
Summary
The facility failed to obtain timely laboratory services as per physician's orders for a resident, leading to an Immediate Jeopardy situation. The resident, who had been prescribed Depakote for dementia and anxiety disorder, required a valproic acid level test ordered by their nurse practitioner. However, the test was not conducted, resulting in the resident being hospitalized with valproic acid toxicity. The resident was admitted to the hospital after being observed as lethargic and unresponsive, with a valproic acid level significantly above the normal range. The facility's Director of Nursing (DON) acknowledged that routine labs were scheduled for specific days, but there was no documented evidence that the lab order was executed. The consulting pharmacist emphasized the importance of monitoring valproic acid levels due to the risk of toxicity. Interviews with facility staff revealed a lack of explanation for the failure to conduct the test. The Chief Operating Officer (COO) and DON were informed of the Immediate Jeopardy, and the COO was responsible for quality improvement efforts. Despite the CEO's disagreement with the Immediate Jeopardy classification, no additional evidence was provided to dispute the findings.
Removal Plan
- A daily audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
- Education will include the physician and their extenders, clinical managers, and facility nurses. Nurses will receive this in-service prior to their next scheduled shift.
- Education started immediately.
- Daily monitoring will begin of any lab orders, old or new, making sure the order has been accurately and successfully carried out and that the results have been communicated to the medical doctor or nurse practitioner office.
- The Director of Nursing or her designee will review lab orders in point click care, lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
- Daily review of labs will continue for one month after such time this will be reviewed weekly in the high-risk meeting.
- Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
- Lab orders will be added as one of the agenda items to be discussed during morning stand up meeting.
Failure to Implement Physician Lab Orders Leads to Resident Hospitalization
Penalty
Summary
The facility's administrative staff failed to effectively oversee the implementation of physician laboratory orders, resulting in a deficiency. Specifically, the facility did not ensure that a valproic acid level was drawn for a resident after it was ordered by the resident's nurse practitioner. This oversight led to the resident being hospitalized with valproic acid toxicity, a condition that can lead to severe health consequences. Interviews and record reviews revealed that the Director of Nursing (DON) was responsible for ensuring laboratory orders were carried out. However, there was no documented evidence that the laboratory services were performed as ordered. The DON indicated that after a lab order is placed, it is given to the floor nurse to enter into the computer, but could not explain why the valproic acid level was not drawn for the resident. The Chief Operating Officer (COO) was in charge of quality and identified problems from grievances and surveys, but the deficiency was not addressed in time to prevent the resident's hospitalization. The Chief Executive Officer (CEO) did not initially recognize the situation as an Immediate Jeopardy, and no additional communication or documentation was provided to dispute the findings. This lack of administrative oversight had the potential to affect all residents with medications requiring lab orders.
Removal Plan
- The facility planned to improve communication between nursing, pharmacy consult, and medical doctors and put more oversight by leadership of the laboratory process.
- A daily audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
- S6Chief Executive Officer (CEO) or his designee will do a visual check to ensure the audits have occurred.
- S6CEO or his designee will attend one high risk meeting to verify lab orders are being reviewed.
- Education will include the physician and extenders, clinical managers, and facility nurses. A daily review will be completed by S2DON or her designee to ensure nothing is missed or not followed up on timely.
- S6CEO or his designee will verify education has been completed as stated through a visual review of the sign in sheets.
- All staff nurses will be in-serviced on the lab order protocol.
- S6CEO/his designee began providing administrative staff with the same education that is being provided to the nurses.
- All administrative staff at the facility will be in-serviced.
- Daily monitoring began of any lab orders, old or new.
- Verification that the order has been accurately and successfully been carried out and that the results have been communicated to the medical doctor or nurse practitioner office. These audits are to be done by S2DON or her designee.
- S2DON or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
- S6CEO or his designee will verify the audits and will participate in one high risk meeting to verify compliance.
- Daily review of labs began and will continue after such time this will be reviewed in the high-risk meeting.
- Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
- Lab orders will be added as an agenda item in the daily, weekday, stand-up meeting.
- S6CEO or his designee will attend one stand up meeting to ensure the agenda remains unchanged.
Facility Fails to Maintain Safe and Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a safe and clean environment for a resident, as evidenced by two specific deficiencies. Firstly, maintenance services did not place an outlet cover over a wall socket in the resident's room, which was observed on two separate occasions. Secondly, housekeeping services failed to clean an unknown brown substance off the floor near the resident's bed, which was also noted during both observations. These issues were confirmed by the Chief Operating Officer, who acknowledged the absence of the outlet cover and the presence of the substance on the floor.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care for Resident #1, who required substantial/maximal assistance for toileting and personal hygiene. According to the Minimum Data Set with an assessment reference date of 01/24/2025, Resident #1 was incontinent of bowel and bladder, and the care plan included an intervention to check the resident every 2 hours for incontinence. However, on 03/10/2025 at 6:32 AM, an observation revealed that Resident #1 had a bowel movement leaking from the adult brief onto her abdomen, incontinent pad, and bed sheets, indicating that the incontinence care was not provided as required. The bowel movement was wet in the center and dry around the edges, suggesting it had been there for some time. In an interview, S4CNA stated that the last time Resident #1 was checked and changed was around 3 AM, which was not in compliance with the 2-hour check requirement. S2Director of Nursing confirmed that Resident #1 should be checked every 2 hours for incontinence.
Failure to Use Proper PPE During EBP
Penalty
Summary
The facility failed to ensure that staff utilized the correct personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). Specifically, a Certified Nursing Assistant (CNA) entered the room of a resident on EBP without wearing a gown and proceeded to empty the resident's urinary catheter, contrary to the facility's policy which requires gowns and gloves to be worn during such procedures. The CNA admitted to not using a gown and was unaware of the requirement. The Director of Nursing and the Infection Preventionist both confirmed that gowns should be worn when emptying urinary catheters for residents on EBP.
Facility Restricts Resident Visitation Hours
Penalty
Summary
The facility failed to honor residents' rights to receive visitors of their choosing at any time, as required by regulations. The facility's visitation policy, which was undated, encouraged visits only between 8:00 AM and 8:00 PM, with any exceptions requiring approval from the Administrator or Director of Nursing. There was no documented evidence that these visitation restrictions were based on clinical or safety concerns. Interviews with a resident and staff members, including a receptionist and a CNA, confirmed that visitors were not allowed outside of these hours, and no exceptions were made. The Administrator acknowledged that residents should be allowed unrestricted visitation, indicating a discrepancy between the policy and the facility's practice.
Failure to Provide Adequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as Resident #32, who required dialysis services. The deficiencies included the lack of assessment of the resident's dialysis access site and failure to obtain vital signs upon the resident's return from dialysis. The facility's records showed multiple instances where there was no documented evidence of these assessments and vital sign checks on various dates from December 2024 to January 2025. Additionally, there was a lack of communication with the dialysis center regarding the resident's condition on several occasions. Interviews conducted with the resident and facility staff confirmed these deficiencies. The resident reported that the facility staff did not check his dialysis access site upon his return from the dialysis center. An LPN admitted to not obtaining the resident's vital signs after dialysis on a specific date, and the DON acknowledged that the facility's process required staff to assess the dialysis access site and document vital signs on the dialysis communication sheets. These failures were identified as part of the facility's deficient practices in providing dialysis care.
Improper Labeling and Disposal of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin pens, leading to a deficiency in medication management. During an observation of Medication Cart A, it was found that several insulin pens belonging to different residents were either not labeled with the date they were opened or were available for use beyond the recommended 28 to 30 days after opening. Specifically, Resident #10's Humulin R insulin pen, Resident #36's Humulin R and Lantus insulin pens, and Resident #40's Novolog and Humulin insulin pens were all found to be improperly labeled or expired. Interviews with the LPN and the Director of Nursing confirmed that the facility's policy required insulin to be discarded 28 days after opening and that the medications in question had been opened over 30 days ago.
Resident's Right to Smoke Restricted by Facility's Policy
Penalty
Summary
The facility failed to uphold a resident's right to make choices regarding smoking, specifically for Resident #32, who was identified as a safe smoker. The facility's Resident Rights policy indicated that residents should be encouraged to exercise their rights, including the use of tobacco in accordance with applicable policies. However, the facility's Smoking policy restricted smoking to designated areas outside the building, with no documented evidence of agreed-upon smoking hours. Despite Resident #32's cognitive intactness, as indicated by a BIMS score of 15, the resident was not allowed to smoke outside the hours of 7:00AM to 7:00PM, as enforced by facility staff. Interviews with various staff members, including the Smoking Aide, Receptionist, CNA/Receptionist, Director of Nursing, and Administrator, confirmed that the facility restricted smoking to the hours of 7:00AM to 7:00PM. This restriction was due to the Smoking Aide's working hours, and staff were instructed to prevent residents from smoking outside these times. The Administrator acknowledged that security staff should not have been stopping residents from smoking outside the designated hours, indicating a lack of adherence to the resident's rights as outlined in the facility's policies.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status documented in the medical record was consistent with the resident's wishes. Specifically, for one resident, there was a discrepancy between the code status indicated in the resident's chart/medical record and the electronic medical record (EMR). The resident's chart/medical record indicated a Full Code status, meaning medical interventions would be performed in the event of no pulse or breath, while the EMR and physician's orders indicated a Do Not Resuscitate (DNR) status, instructing healthcare providers not to perform cardiopulmonary resuscitation (CPR). Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) would rely on the resident's chart/medical record to verify code status during an emergency, which showed a Full Code status. However, the Director of Nursing (DON) confirmed the discrepancy, acknowledging that the EMR and physician's orders indicated a DNR status. This inconsistency in documentation could lead to confusion and inappropriate medical interventions, highlighting a failure in maintaining accurate and consistent records of the resident's code status according to their wishes.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) forms to residents prior to the termination of Medicare Part A services. This deficiency was identified for three residents who were sampled for termination of Medicare Part A services. For each resident, there was no documented evidence that the NOMNC Form CMS-10123 was given, explained, or signed by the residents or their responsible parties before the discontinuation of services. The facility was unable to present any documentation to confirm that these forms were properly handled. Resident #62, Resident #68, and Resident #234 were all affected by this deficiency. Resident #62's last day of Medicare Part A services was on 07/29/2024, Resident #68's on 08/07/2024, and Resident #234's on 12/09/2024. In each case, the facility's administrator confirmed the lack of documentation and explanation of the NOMNC forms. Additionally, the SNFABN forms were signed inadvertently without proper explanation to the residents or their responsible parties. Resident #68 was noted to have severe cognitive impairment, which further emphasizes the importance of ensuring that responsible parties are adequately informed and involved in the process.
Inaccurate Dental Assessments for Two Residents
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments for two residents regarding their dental status. Resident #61 was admitted with moderate cognitive impairment, as indicated by a BIMS score of 11. However, the admission Minimum Data Set (MDS) assessment inaccurately reported no oral and dental issues, despite observations and the resident's own admission of missing several teeth. The facility administrator could not provide an explanation for this discrepancy. Similarly, Resident #75, who had an intact cognitive status with a BIMS score of 15, was also inaccurately assessed as having no dental issues upon admission. Observations and interviews with the resident and two LPNs confirmed that the resident was missing several teeth at the time of admission. Again, the facility administrator was unable to explain the inaccuracy in the MDS assessment for this resident's dental status.
Failure to Maintain Level II PASARR Documentation
Penalty
Summary
The facility failed to provide documentation of a resident's Level II Pre-Admission Screening and Resident Review (PASARR) for one of the sampled residents. The medical record of the resident, who was admitted with diagnoses of Schizophrenia, Bipolar Disorder, and Unspecified Dementia, did not contain the necessary Level II PASARR documentation. This documentation was supposed to be completed by the Office of Behavioral Health and maintained in the resident's medical record. During interviews, both the social services staff and the administrator acknowledged the absence of the required documentation in the resident's medical record, confirming that it should have been maintained.
Failure to Supervise Unsafe Smoker
Penalty
Summary
The facility failed to ensure safe smoking interventions for a resident identified as an unsafe smoker. Resident #45, who was admitted with diagnoses including vascular dementia, tremors, and epilepsy, was listed on the facility's Unsafe Smoker List. The resident had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The care plan for Resident #45 required supervision while smoking and specified that smoking supplies should be obtained from a designated smoke aide. During an observation, the smoking aide was seated 10 to 15 feet away from Resident #45, with the resident's back turned towards the aide. Resident #45 was given a cigarette by another resident and had it lit by yet another resident, while facing away from the smoking aide. Interviews with the smoking aide and a certified nursing assistant confirmed that Resident #45 was an unsafe smoker who required direct visualization while smoking. The facility administrator also indicated that unsafe smokers should not receive smoking materials from other residents, highlighting a failure in supervision and adherence to the care plan for Resident #45.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication was not ordered on an as-needed basis for more than 14 days. Specifically, Resident #55 had a physician's order dated 09/28/2024 for Lorazepam, a psychotropic medication used to treat anxiety, to be administered 0.5 mg every eight hours as needed. There was no documented evidence that the physician provided a clinical rationale for the continuation of this order or specified a duration for the medication. During an interview on 01/30/2025, the Director of Nursing acknowledged that the facility should have clarified the duration and the physician's rationale for continuing the medication order for Resident #55.
Failure to Notify Physician of Incomplete Laboratory Test
Penalty
Summary
The facility failed to notify a physician when laboratory tests were not completed as ordered for a resident. A pharmaceutical consultant recommended a Complete Blood Count (CBC) for the resident every six months, and a physician's order was placed to begin this schedule. However, there was no documented evidence that the CBC was completed in January 2025 as ordered. The laboratory results indicated that the CBC was not completed due to the laboratory's inability to obtain a blood specimen, yet there was no documentation of the physician being informed of this issue. During an interview, the Director of Nursing acknowledged that the physician should have been notified if the CBC was not completed, and there should have been documentation of this notification. The lack of communication and documentation regarding the incomplete laboratory test represents a deficiency in the facility's process for ensuring that ordered laboratory services are provided and that physicians are promptly informed of any issues in obtaining test results.
Failure to Provide Dental Services to Residents
Penalty
Summary
The facility failed to provide necessary dental services to two residents, resulting in a deficiency. Resident #61 was observed to be missing several upper and lower teeth and expressed a desire to see a dentist and obtain dentures. Despite being admitted to the facility, there was no documented evidence that Resident #61 had been evaluated for dental services. The facility's dental treatment schedule did not include Resident #61, and interviews with social services and the administrator confirmed the lack of evaluation without providing a reason. Similarly, Resident #75 was also missing several teeth and had not seen a dentist since admission, despite expressing a desire for dental services and dentures. Like Resident #61, there was no documented evidence of a dental evaluation for Resident #75, and the resident was not listed on the facility's dental treatment schedule. Interviews with social services and the administrator again confirmed the absence of dental evaluation, with no explanation provided for this oversight.
Facility Dumpster Not Maintained Sanitarily
Penalty
Summary
The facility failed to maintain its dumpster in a sanitary manner, as observed on two separate occasions. On January 28, 2025, at 10:35 AM and again at 12:40 PM, the dumpster was found to be missing a lid and was open to the air, with loose trash scattered on the ground around it. Interviews with the Dietary Manager and the Administrator confirmed awareness of the missing lid and acknowledged that the trash should have been contained. Both staff members admitted that the dumpster and its surrounding area were not maintained in a sanitary manner, as they should have been.
Lack of Involvement in Facility Assessment
Penalty
Summary
The facility failed to ensure active involvement from direct care staff, residents, and residents' representatives in the development of its facility-wide assessment. The assessment, dated on an unspecified date, lacked documented evidence of participation from a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), a resident, and/or a resident representative. This deficiency was confirmed during an interview with the facility's administrator on January 30, 2025, who acknowledged the absence of such documentation.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents, despite having signed consents for the vaccinations. Resident #43 signed a consent form to receive the pneumococcal vaccine on April 5, 2024, but there was no documented evidence that the vaccine was administered or that it was medically contraindicated. Similarly, Resident #81's responsible party signed a consent for the pneumococcal vaccine on October 11, 2024, yet there was no documentation to confirm the vaccine was given or medically contraindicated. Interviews with the facility's administrator confirmed the lack of documentation for both residents, indicating a failure in the facility's vaccination administration process.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure the administration of the COVID-19 vaccine to a resident, despite having obtained consent from the resident's responsible party. Specifically, the consent for the COVID-19 vaccine for Resident #81 was signed on 10/11/2024, but there was no documented evidence that the vaccine was administered or that it was medically contraindicated. During an interview on 01/30/2025, the administrator confirmed the lack of documentation regarding the administration or contraindication of the vaccine for Resident #81.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and review individualized fall prevention interventions for three residents who experienced multiple falls. Resident #1, who had severe cognitive impairment and used a manual wheelchair, experienced several falls, including an unwitnessed fall with injury. Despite the facility's policy requiring new interventions after each fall, there was no documented evidence that these interventions were implemented or reviewed for effectiveness. Interviews with the Director of Nursing and staff confirmed the lack of documentation and updates to the resident's care plan. Resident #2, also with severe cognitive impairment and a history of falls, experienced multiple falls, including one with injury. The facility's records showed no evidence of individualized post-fall interventions being implemented or reviewed for effectiveness. Staff interviews revealed that updates on fall interventions were not communicated to those primarily responsible for the resident's care. Resident #3, who was cognitively intact but had vision and hearing impairments, experienced several falls, including one with injury. The care plan was not updated with new interventions or increased supervision after these incidents. Interviews with nursing staff and CNAs confirmed the absence of documented evidence for new interventions and a lack of communication regarding updates to the resident's fall prevention strategies.
Failure to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, as observed during a survey. For one resident, a brown smear was noted on the wall above the trash can in their room, which was confirmed by the administrator. This indicates a failure to adhere to the facility's Bathroom Policy, which requires daily cleaning of walls, wash basins, commodes, and floors. For another resident, multiple observations revealed significant unsanitary conditions in their room and bathroom. The isolation cart outside the room was visibly dirty, and the room itself had a brown substance on the wall, dirt on the bedside table and floor, and a chicken bone under the table. Additionally, nutrition shakes were found on the floor next to unlabeled and uncovered urinals, and the bedside table was cluttered with an unopened breakfast plate, a cup with ointment remnants, and a water pitcher with a brownish film. The bathroom had a brown substance smeared on the toilet seat and base, and toothpaste was spilled on the counter. Interviews with the housekeeper, DON, and facilities manager confirmed the unsanitary conditions, and the resident expressed dissatisfaction with the cleanliness of their room and bathroom.
Incomplete Investigation of Resident's Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect concerning an injury of unknown origin for a resident. The resident was found to have a dislocated left hip, which was discovered in the morning after being put to bed the previous evening with an abductor cushion in place. The facility's investigation was incomplete, as it did not include statements from all relevant staff members who were present during the time of the incident. The investigation documentation revealed that only two statements from CNA staff were obtained, and there was no evidence of statements from other staff members who had observed the resident's condition. Notably, the LPNs who assisted with the resident's care during the night shift did not document their observations of the resident's swollen hip, nor were they asked to provide statements about their knowledge of the incident. Additionally, a CNA who noticed the resident's hip condition during breakfast was not questioned or asked to provide a statement. Interviews with the Director of Nursing and the Administrator confirmed that they did not obtain statements from all nursing staff involved, believing it was only necessary to get statements from direct care staff. This oversight resulted in a lack of comprehensive documentation and understanding of the events leading to the resident's injury, as required by the facility's abuse prevention policy.
Failure to Revise Care Plan After Resident Falls and ADL Decline
Penalty
Summary
The facility failed to revise a resident's care plan to address significant changes in their condition, specifically a decline in activities of daily living (ADLs) and incidents of falls. The resident, who had severely impaired cognition with a BIMS score of 3, was dependent on staff for transfers and mobility. The resident experienced a witnessed fall from a wheelchair resulting in a left hip fracture and an unwitnessed fall from bed with no apparent injury. Despite these incidents, the care plan was not updated to reflect the falls or the decline in bed mobility and transfers due to the hip fracture. This deficiency was confirmed during an interview with the facility administrator.
CNA Found Asleep on Duty
Penalty
Summary
The facility failed to ensure that staff was available at all times to provide care and services to meet the residents' needs, as evidenced by a Certified Nursing Assistant (CNA) being observed asleep while on duty. The CNA, identified as S6CNA, was assigned to provide care to seven residents during a day shift from 7:00 a.m. to 7:00 p.m. on floor x. On the day of the observation, the CNA was found slouched over in a chair with eyes closed in the hallway, indicating he was asleep. This incident was observed by administrative staff and later confirmed by the Director of Nursing (DON), who woke the CNA and addressed the issue. The CNA had previously signed the facility's Employee Code of Conduct, which explicitly stated that sleeping while on duty was a violation warranting immediate termination. Despite this, the CNA was found asleep during his shift, which was confirmed through interviews with both the CNA and the facility's Administrator. The Administrator confirmed that the CNA should not have been asleep while on duty, highlighting a failure to adhere to the facility's staffing requirements and code of conduct.
Uncertified Staff Working Independently as Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were trained and competent, and that those who had worked less than four months were enrolled in appropriate training. This deficiency was identified for eight staff members, including direct service workers and a front desk receptionist, who were working independently as nurse aides without meeting the minimum state-approved competency and training requirements. The Immediate Jeopardy occurred when these staff members were allowed to work independently with residents, providing direct care without the necessary certification or supervision. The survey team observed multiple instances where uncertified staff were working independently throughout the facility. For example, S4DSW was seen working on various floors and confirmed in an interview that she had not taken the state-approved certification test despite completing a CNA course. Similar findings were noted for S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR, all of whom were working independently as nurse aides without having met the required competency and training standards. Interviews with these staff members revealed that they were not currently enrolled in or scheduled for any CNA certification courses. The facility's policy and procedure required sufficient qualified nursing staff to provide safe and effective care to residents. However, the review of personnel files, time cards, and CNA Break and Lunch Schedule Sheets indicated that uncertified staff were assigned to work independently, providing direct care to residents. Interviews with the Human Resources Manager, Director of Nursing, and Administrator confirmed that they were unaware of the certification status of these staff members, leading to a situation where all 79 residents in the facility were at risk of harm due to the actions of uncertified staff providing direct care without supervision.
Failure to Ensure Staff Competency and Training Requirements
Penalty
Summary
The facility failed to ensure that staff working as nurse aides met the minimum state-approved competency and training requirements. This deficiency was identified for 8 out of 13 personnel files reviewed. The lack of administrative oversight resulted in an Immediate Jeopardy situation when the facility allowed unqualified staff to work independently as nurse aides, providing direct care to residents without the necessary certification or training. This situation persisted over several months, as evidenced by time cards and schedule sheets reviewed by the survey team. The Immediate Jeopardy was identified on 02/09/2024, when staff members S4DSW, S11DSW, and S12DSW were observed working independently without the required qualifications. Further review of the CNA Break and Lunch Schedule Sheets revealed that additional staff members, including S5DSW, S6DSW, S7DSW, S8DSW, and S15FDR, were also assigned to work as nurse aides without meeting the state-approved competency and training requirements. Interviews with the Human Resources Manager, Director of Nursing, and Administrator confirmed that these staff members were not certified and were improperly assigned to provide direct care to residents. The Administrator acknowledged awareness of the situation and confirmed that all 79 residents were at risk of serious injury or harm due to the actions of the uncertified staff. The Human Resources Manager admitted to being unaware that the facility could not hire DSWs to provide direct care, and the Director of Nursing assumed that only certified staff were hired. The Chief Compliance Officer also stated that he was unaware of the situation and emphasized that uncertified staff should not have been allowed to work as nurse aides. The Immediate Jeopardy was removed on 04/04/2024 after the facility implemented an acceptable Plan of Removal.
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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