The Broadway Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Lockport, Louisiana.
- Location
- 7534 Highway 1, Lockport, Louisiana 70374
- CMS Provider Number
- 195583
- Inspections on file
- 25
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Broadway Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
An unlicensed individual worked as an LPN without a valid Louisiana nursing license, affecting 87 residents. The individual was promoted from CNA to LPN without proper licensure verification, leading to an immediate jeopardy situation. The facility's failure to verify licensure before allowing the individual to provide nursing care posed a risk of serious harm to residents.
A facility failed to verify the licensure of an unlicensed personnel who worked as an LPN, affecting 87 residents. The personnel's status was changed from CNA to LPN without verifying the necessary licensure, and they provided care without passing the NCLEX-PN in Louisiana. The oversight led to an immediate jeopardy situation due to the risk of serious harm from unlicensed nursing services.
A resident with type 2 diabetes mellitus did not receive scheduled doses of Novolog on multiple occasions, and the facility failed to notify the physician as required by their policy. The eMAR indicated the medication was either held or deemed not required, but there was no documentation of physician notification, as confirmed by facility staff.
The facility did not meet the required CNA staffing levels on two consecutive days, as per its own assessment. The facility's assessment required 19 CNAs for the day shift, 12 for the evening shift, and 8 for the night shift, but staffing sheets showed fewer CNAs were present. Interviews revealed that an LPN often worked without CNAs during shift changes, and the administrator admitted to typically staffing fewer CNAs than required. The COO acknowledged the need to staff according to the facility assessment.
A facility failed to ensure medication availability and proper reconciliation of controlled substances. Three residents did not receive prescribed medications due to unavailability, and multiple medication carts had incomplete reconciliation records. Staff interviews confirmed these deficiencies, highlighting lapses in following facility policies.
A resident's grievance regarding nursing care was not properly documented or resolved according to the facility's grievance policy. The grievance report lacked necessary details such as confirmation status, resolution, and notification to the resident or their responsible party. The Social Service Director was unaware of the resolution, and the administrator admitted to not completing the investigation or documentation.
The facility failed to report an incident of neglect within the required 24-hour timeframe. An unlicensed personnel worked 37 shifts as an LPN without a valid license, posing a risk of serious harm. The incident was discovered but not reported to the state agency until several days later, violating state regulations.
A resident with type 2 diabetes had multiple instances of elevated blood sugar levels exceeding 250 mg/dL, yet the facility failed to notify the physician as required by the medical orders. The DON confirmed the absence of documentation indicating physician notification, highlighting a lapse in following prescribed care protocols.
Two residents in the facility received incorrect medications, leading to a 7.6% medication error rate. One resident was given a lower dosage of Valsartan/HCTZ than prescribed, while another received the wrong type of eye drops. Both errors were confirmed by the LPNs involved and the facility administrator.
A facility failed to provide planned restorative services to residents due to staffing reassignments. Restorative aides were pulled to work on the floor, resulting in the omission of essential services like range of motion exercises and walking assistance for residents. This deficiency was confirmed through staff interviews and record reviews.
The facility failed to provide adequate safety measures for two residents, one with severe cognitive impairment and a high risk of falls, and another requiring two-person assistance for transfers. The first resident's interventions were ineffective, with staff unable to explain their purpose, and the resident unable to understand them. The second resident was transferred by a CNA without the required assistance, resulting in a bruise. These deficiencies highlight the facility's failure to adhere to care plans and implement effective safety measures.
A resident with hemiplegia was repeatedly found with her adaptive call light out of reach, despite being dependent on staff for ADLs and having a care plan that required the call light to be accessible. The resident expressed difficulty in reaching the call light, and a CNA confirmed her ability to use it, highlighting a failure to accommodate her needs.
A resident with dysphagia requiring tube feeding did not receive enteral nutrition as ordered. The facility's policy required verification of pump settings each shift, but the feeding was observed at an incorrect rate and not stopped at the designated time. Interviews revealed that the LPN was unaware of the order change, and the night nurse could not recall verifying or stopping the feeding as required.
A resident with dysphagia and severe cognitive impairment was served the incorrect diet, receiving regular rice instead of the prescribed pureed rice. The resident's care plan required a mechanically altered diet to prevent aspiration, but the meal served did not adhere to these dietary instructions, as confirmed by facility staff.
The facility failed to develop and implement an appropriate care plan for a cognitively impaired resident at high risk for falls. The care plan included interventions unsuitable for the resident's cognitive abilities, such as using a call light and bright signage, which were not present or effective. Staff confirmed the resident's inability to use these interventions, leading to the identification of this deficiency.
The facility failed to ensure proper handling of soiled towels and the appropriate positioning of urinary catheter bags for several residents. A CNA placed soiled towels on a bedside table, and catheter bags were observed touching the floor, which was confirmed as improper by the DON and Administrator. These actions breached infection control practices.
The facility failed to report a fall resulting in serious injury and an alleged incident of sexual abuse to the State Survey Agency. A resident experienced a fall causing fractures, and another resident exposed himself and attempted to kiss a staff member. Both incidents were not reported as required.
The facility failed to investigate an alleged sexual abuse incident involving a resident with severe cognitive impairment who exposed himself to another resident and attempted to kiss an OT. Despite awareness of the incident, the Administrator did not conduct a thorough investigation, and multiple staff members were not interviewed.
Unlicensed Personnel Worked as LPN Without Verification
Penalty
Summary
The facility failed to ensure that personnel had the appropriate state licensure to provide care and services to residents. This deficiency was identified when an unlicensed individual, referred to as S5Unlicensed Personnel, worked in the capacity of a Licensed Practical Nurse (LPN) without holding a valid Louisiana nursing license. The individual was initially employed as a Certified Nurse Aide (CNA) and was later promoted to an LPN position without proper verification of licensure. This oversight led to the individual performing nursing tasks and providing care to residents without the necessary qualifications. The deficiency was discovered when it was revealed that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) and did not have an active Practical Nurse License in the state of Louisiana. Despite this, the individual was allowed to start training and perform duties as an LPN under the supervision of other licensed nurses. The Director of Nursing (DON) and the Administrator were both involved in the decision to change the individual's status and allow them to perform LPN duties without verifying the licensure status. This practice affected 87 residents who received care from the unlicensed individual. The facility's failure to verify the licensure status of S5Unlicensed Personnel before allowing them to provide nursing care created an immediate jeopardy situation, posing a risk of serious injury, harm, or death to the residents. The deficiency was identified as a past noncompliance citation as corrective actions were implemented prior to the State Agency's investigation.
Removal Plan
- Unlicensed Personnel was suspended and terminated.
- Administrator, DON, and TMS were in-serviced on licensure verification and reporting wrongdoing.
- Cognitive resident interviews were completed by Regional RN regarding any medication administration concerns or other nursing concerns.
- Full facility wide audit started on all nurses to ensure active license in place.
- In-service on reporting wrongdoing was completed by Administrator, DON, TMS, and staff.
- Audits were completed of resident's electronic medical records documentation who received care from Unlicensed Personnel while Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
- TMS to verify licensure prior to nurse hired or role change if currently working. DON would be provided with a copy for double verification at the facility level.
- Corporate Compliance Officer to audit weekly for compliance for three months and annually.
Unlicensed Personnel Performed LPN Duties Without Verification
Penalty
Summary
The facility failed to ensure that personnel had the appropriate state licensure to provide care and services to residents. This deficiency was identified when S5, an unlicensed personnel, worked in the capacity of an LPN and performed nursing tasks without a Louisiana nursing license. The issue was discovered after S5 had been providing care and services to residents from November 20, 2024, until January 24, 2025, affecting 87 residents. The facility's Professional Licensure Verification Policy required that all employees with a professional license be verified upon hire and as required through the appropriate licensure board. However, S5's status was changed from a Certified Nurse Aide (CNA) to an LPN without verifying the necessary licensure. S5 signed the Licensed Staff Job Description, and the facility documentation confirmed that S5 provided care in the capacity of an LPN without having passed the National Council Licensure Examination for Practical Nurses (NCLEX-PN) in Louisiana. Interviews revealed that the Team Member Specialist (TMS) was responsible for verifying licensure but failed to do so before changing S5's status. The Director of Nursing (DON) allowed S5 to start training as an LPN without verifying licensure, and the Administrator directed the status change and allowed S5 to perform LPN duties without ensuring a valid license. This oversight led to an immediate jeopardy situation, as there was a likelihood of serious injury, harm, or death due to having unlicensed personnel providing nursing services.
Removal Plan
- Unlicensed Personnel was suspended and terminated.
- Administrator, DON, and TMS were in-serviced on licensure verification and reporting wrongdoing.
- Cognitive resident interviews were completed by Regional RN regarding any medication administration concerns or other nursing concerns.
- Full facility wide audit started on all nurses to ensure active license in place.
- In-service on reporting wrongdoing was completed by Administrator, DON, TMS, and staff.
- Audits were completed of resident's electronic medical records documentation who received care from Unlicensed Personnel while Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
- TMS to verify licensure prior to nurse hired or role change if currently working. DON would be provided with a copy for double verification at the facility level.
- Corporate Compliance Officer to audit weekly for compliance for three months and annually.
Failure to Notify Physician of Withheld Medication
Penalty
Summary
The facility failed to notify a resident's physician when a scheduled medication, Novolog, was withheld on multiple occasions. The facility's Medication Administration General Guidelines policy requires that medications be administered as ordered by the physician, and if a scheduled medication is withheld, it should be documented with an explanatory note. Furthermore, if several doses of a vital medication are withheld, the physician should be notified, and a response documented. However, for Resident #9, who was admitted with a diagnosis of type 2 diabetes mellitus, there was no documented evidence that the physician was notified when Novolog was not administered as ordered on numerous occasions throughout November 2024. The electronic Medication Administration Record (eMAR) for Resident #9 showed multiple instances where Novolog was not administered, with codes indicating the medication was held or not required. Despite these omissions, there was no documentation in the progress notes or any evidence presented by the facility that the physician was informed of these missed doses. Interviews with the Assistant Director of Nursing and the Corporate Compliance Officer confirmed that the physician should have been notified, but there was no documentation to support that this occurred.
Facility Fails to Meet CNA Staffing Requirements
Penalty
Summary
The facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working according to the facility's assessment on two consecutive days. The facility's assessment indicated that 19 CNAs were needed for the weekday day shift, 12 for the evening shift, and 8 for the night shift. However, the staffing sheets and time records revealed that the facility consistently staffed fewer CNAs than required. For instance, on the day shift of February 5, 2025, only 10 to 11 CNAs were present instead of the required 19. Similarly, the evening and night shifts were also understaffed, with only 6 to 7 CNAs present instead of the required 12 and 8, respectively. Interviews with staff further highlighted the staffing issues. An LPN reported working without CNAs during shift changes, as outgoing CNAs left without giving reports to incoming staff. The facility's administrator acknowledged that they typically staffed fewer CNAs than the assessment required, with only 12 CNAs on the day shift, 8 on the evening shift, and 8 on the night shift. The Chief Operations Officer confirmed that the facility should be staffed according to the facility assessment, indicating a recognition of the deficiency in meeting staffing requirements.
Medication Availability and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for three residents. Resident #1 did not receive Cozaar, doxycycline, and levofloxacin on multiple occasions due to unavailability. Similarly, Resident #8's ciprofloxacin, tamsulosin, and potassium chloride were not administered as ordered, with documentation indicating issues such as waiting on insurance and reordering. Resident #57 also experienced missed doses of hydralazine hydrochloride due to the medication not being available. Interviews with facility staff confirmed the unavailability of these medications and the failure to utilize the Emergency Drug Kit when applicable. Additionally, the facility did not maintain a proper system for reconciling controlled drugs across multiple medication carts. The Narcotic Count Sign Sheets for Medication Carts a, b, and c showed incomplete reconciliation of controlled substances, with missing signatures from nurses on duty during specific shifts. This lack of documentation indicates a failure to adhere to the facility's policy requiring reconciliation at the beginning and end of each shift. Interviews with the Director of Nursing and other staff members acknowledged the deficiencies in medication availability and the incomplete reconciliation of controlled substances. The facility's policies were not followed, leading to lapses in medication administration and documentation, which are critical for ensuring resident safety and compliance with regulatory standards.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly complete and document a grievance report for a resident who filed a nurse-related grievance. The grievance policy and procedure of the facility require that all grievances be documented on a grievance form by the grievance official, which includes details such as the date received, a summary of the grievance, steps taken to investigate, findings, confirmation status, corrective actions, and the date of the written decision. However, the grievance report for the resident was not signed by the administrator, lacked a statement confirming or not confirming the grievance, did not document any resolution or corrective action, and failed to notify the resident or their responsible party of the resolution. Interviews revealed that the Social Service Director, who acted as the grievance official, was unaware of the resolution and had not received the investigation from the administrator. The administrator admitted to not submitting the investigation to the grievance official and confirmed that the grievance report was incomplete and improperly documented. The facility did not provide any documented evidence that the grievance report was properly completed, indicating a failure to adhere to their grievance policy and procedure.
Failure to Timely Report Neglect Due to Unlicensed Practice
Penalty
Summary
The facility failed to report an incident of neglect to the Louisiana Department of Health within the required 24-hour timeframe. The incident involved an unlicensed personnel, identified as S5Unlicensed Personnel, who was working as a Licensed Practical Nurse (LPN) without a valid Louisiana Practical Nurse License. This individual worked 37 shifts as an LPN from November 20, 2024, to January 23, 2025, without having passed the NCLEX-PN, a standardized test required for LPN licensure. The facility's policy mandates that neglect, defined as the failure to provide necessary goods and services to avoid harm, should be reported promptly to the state agency. The incident was discovered on January 24, 2025, when S7Team Member Specialist/Human Resources informed the facility's administrator, S1Administrator, about the lack of a valid nursing license for S5Unlicensed Personnel. Despite the potential for serious injury or harm due to the unlicensed practice, the report was not submitted to the Statewide Incident Management System (SIMS) until January 31, 2025, which was beyond the 24-hour reporting requirement. This delay in reporting constitutes a deficiency in the facility's compliance with state regulations regarding the timely reporting of neglect.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to adhere to physician's orders for a resident diagnosed with type 2 diabetes mellitus, which required blood glucose monitoring before meals and at bedtime. The physician's orders specified that the staff should notify the physician if the resident's blood sugar levels were less than 60 mg/dL or greater than 250 mg/dL. However, a review of the resident's blood sugar records for January 2025 revealed multiple instances where the blood sugar levels exceeded 250 mg/dL, with no documented evidence that the physician was notified as required. The resident's blood sugar levels were recorded as significantly high on several occasions, with readings reaching as high as 569 mg/dL. Despite these elevated levels, there was no documentation to indicate that the physician was informed, as confirmed by the Director of Nursing during an interview. This lack of communication with the physician represents a failure to comply with the established medical orders, potentially compromising the resident's health management.
Medication Administration Errors Result in 7.6% Error Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, resulting in a medication error rate of 7.6%. For Resident R1, the physician's order specified the administration of Valsartan-Hydrochlorothiazide (HCTZ) 160-25 mg tablet once a day. However, an LPN administered a Valsartan/HCTZ 160/12.5 mg tablet instead. This discrepancy was confirmed through observation and an interview with the LPN, who acknowledged the error. The facility administrator also confirmed that the resident did not receive the medication as ordered by the physician. For Resident R2, the physician's order required the administration of Artificial Tears Ophthalmic Solution 1% Carboxymethylcellulose Sodium eye drops, with one drop to be instilled in both eyes every six hours. Instead, an LPN administered Advance Relief Eye Drops containing Polyethylene Glycol 400 1% and Tetrahydrozoline HCI 0.05%, which are used for treating allergic reactions in the eyes. This error was also confirmed through observation and an interview with the LPN, who admitted to administering the wrong medication. The facility administrator corroborated that the incorrect medication was given to Resident R2.
Failure to Provide Restorative Services Due to Staffing Reassignment
Penalty
Summary
The facility failed to ensure that residents received planned restorative services, which are essential for maintaining their ability to perform activities of daily living. The deficiency was identified through interviews, policy reviews, and record reviews, revealing that 12 residents did not receive the necessary restorative services such as active and passive range of motion exercises, walking assistance, and eating/swallowing support. These services were outlined in the residents' task schedules, but were not provided as required. The facility's policy on restorative programs mandates that residents be assessed for potential benefits and that specific programs be implemented under the supervision of a licensed nurse. However, the report indicates that on a specific date, restorative aides were reassigned to other duties, resulting in the omission of restorative services for all sampled residents. This lack of service provision was confirmed through multiple staff interviews, including those with CNAs and the Assistant Director of Nursing, who acknowledged that the restorative services were not conducted as scheduled. The report highlights that the failure to provide these services was due to staffing issues, as restorative aides were pulled to work on the floor, leaving no personnel to carry out the restorative programs. This oversight affected residents who were supposed to receive various forms of assistance, including range of motion exercises and walking with support, which are critical for maintaining their functional abilities.
Failure to Implement Safety Measures for Residents at Risk
Penalty
Summary
The facility failed to ensure adequate interventions for a cognitively impaired resident with a high risk of falls. The resident, who had severe cognitive impairment and a history of falls, did not have effective interventions in place to mitigate the risk of future falls. Observations revealed that the bright colored tape intended to assist the resident was either peeling or absent, and the resident was unable to understand the purpose of the tape or the sign posted as a reminder to call for assistance. Interviews with staff indicated a lack of understanding of the interventions' purpose, and there was no evidence that the resident comprehended the safety measures. Additionally, the facility did not provide adequate assistance for a resident requiring two-person assistance with transfers. Despite the resident's care plan indicating the need for two staff members during transfers, a CNA attempted to transfer the resident alone, resulting in the resident sustaining a bruise. The incident was witnessed by the resident's roommate and confirmed by multiple staff members, including the CNA involved, who acknowledged the failure to follow the care plan. These deficiencies highlight the facility's failure to implement and adhere to appropriate safety measures for residents at risk of falls and those requiring significant assistance with mobility. The lack of effective interventions and adherence to care plans contributed to the residents' increased risk of accidents and injuries.
Failure to Ensure Resident's Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's adaptive call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. Resident #5, who has a diagnosis of hemiplegia affecting both sides of the body and is dependent on staff for activities of daily living (ADLs), was observed multiple times with the adaptive call light out of reach. The resident's care plan specifically required staff to ensure the call light was accessible, yet observations on three separate occasions revealed the call light was placed above the resident's left shoulder, making it inaccessible. Interviews with Resident #5 confirmed that she was aware of how to use the adaptive call light but was unable to locate it or reach it when needed. The resident expressed that it was bothersome not to be able to reach the call light to request staff assistance. A Certified Nursing Assistant (CNA) acknowledged that the resident was dependent on staff for all ADLs and confirmed the resident's ability to use the call light. Despite this, the call light remained out of reach, indicating a failure to adhere to the care plan and accommodate the resident's needs effectively.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to administer enteral feeding as ordered for a resident with dysphagia who required nutrition and hydration through a feeding tube. The facility's policy required nurses to enter the amount to be infused according to the physician's order and verify pump settings each shift. However, on observation, the resident's feeding was found to be infusing at 55 mL/hour instead of the ordered 65 mL/hour, and it was not stopped at the designated time of 6:00 AM. Interviews revealed that the LPN responsible for the resident's care was unaware of the recent change in the physician's order and confirmed the feeding should have been stopped at 6:00 AM. The Assistant Director of Nursing indicated that the night nurse was responsible for stopping the feeding, but the night nurse could not recall verifying the infusion rate or stopping the feeding as required. This oversight led to the resident receiving incorrect enteral feeding, contrary to the physician's orders.
Failure to Provide Correct Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide a resident with the correct diet to meet their needs, specifically for a resident with dysphagia following a cerebral infarction. The resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5, was on a mechanically altered diet to reduce the risk of aspiration. The resident's care plan and meal ticket specified a mechanical soft diet with chopped meats and pureed rice, along with specific instructions to avoid certain foods and items such as soup, cereal & milk, gumbo, straws, and to have puree rice only. On the day of the incident, the resident was observed being served a meal that included regular rice instead of the prescribed pureed rice, along with other items like white beans, chopped sausage, mustard greens, a slice of bread, and a piece of cake. This was confirmed by a Certified Nursing Assistant who noted the discrepancy between the meal ticket and the food served. The Assistant Director of Nursing (ADON) also confirmed that the resident was served the wrong diet, acknowledging the error in providing regular rice instead of pureed rice during the lunch meal service.
Inadequate Person-Centered Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a person-centered plan of care that consisted of individualized interventions reflective of a resident's status was developed and implemented for a resident with severe cognitive impairment and a high risk for falls. Resident #69, who had diagnoses including stroke, hemiplegia, aphasia, and post-traumatic head trauma, was admitted on 03/18/2024. The resident's Re-entry Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 2, identifying severe cognitive impairment. Despite being assessed as high risk for falls, the care plan included interventions such as using a call light, bright signage, and bright tape on wheelchair brakes, which were not appropriate given the resident's cognitive limitations. Observations revealed the absence of the specified signage and tape, and interviews with staff confirmed that the resident was unable to use the call bell or understand the interventions due to cognitive impairment. The deficiency was identified through interviews, observations, and record reviews. Staff interviews indicated that the care plan interventions were not suitable for Resident #69's cognitive abilities. The resident was observed to be confused and unable to communicate needs effectively. The facility's failure to develop and implement a care plan with appropriate, individualized interventions for Resident #69, who was at high risk for falls and had severe cognitive impairment, led to the identification of this deficiency. The care plan did not reflect the resident's actual needs and capabilities, resulting in inadequate fall prevention measures.
Infection Control Deficiencies in Handling Soiled Towels and Catheter Bags
Penalty
Summary
The facility failed to ensure proper handling of soiled towels and the appropriate positioning of urinary catheter bags for several residents. Specifically, a CNA was observed placing soiled towels used for urinary catheter and incontinence care on a resident's bedside table, which was confirmed as inappropriate by the CNA, DON, and ADON/Infection Preventionist. This action was observed multiple times during the care of a resident with an indwelling urinary catheter, indicating a breach in infection control practices as per the facility's Perineal Care Policy and Procedure. Additionally, the facility failed to ensure that urinary catheter bags were not touching the floor for three residents. Observations revealed that the catheter bags of these residents were uncovered and in contact with the floor, which was acknowledged as improper by the DON and the Administrator. These residents had diagnoses related to bladder dysfunction and a history of urinary tract infections, making the proper handling of catheter bags crucial to prevent infections. The failure to maintain catheter bags off the floor was observed on multiple occasions, highlighting a significant lapse in infection control measures within the facility.
Failure to Report Serious Injury and Alleged Sexual Abuse
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury and an alleged incident of sexual abuse to the State Survey Agency. Resident #69 experienced an unobserved fall on 03/15/2024, which resulted in a fractured femur and pelvis. Despite the severity of the injuries, the facility did not document or report the incident on the Statewide Incident Management System (SIMS). The Administrator confirmed that no report was made for this major injury incident during an interview on 05/28/2024. Additionally, Resident #118, who has a diagnosis of unspecified dementia and severely impaired cognition, was involved in an incident on 05/06/2024 where he exposed himself to another resident and attempted to kiss a staff member. Despite being aware of the incident, the Administrator did not report it to the State Survey Agency, citing the resident's cognitive impairment as the reason. Interviews with the involved staff and the affected resident confirmed the occurrence of the incident, and the Administrator acknowledged the lack of documentation and reporting during an interview on 05/30/2024.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure an alleged incident of sexual abuse was thoroughly investigated for Resident #118, who had a diagnosis of Unspecified Dementia and a severely impaired cognition score. On 05/06/2024, Resident #118 was found exposing himself to Resident #67 in her room, and later that day, he attempted to kiss an Occupational Therapist multiple times. Despite these incidents, there was no documented evidence of a thorough investigation to determine if Resident #118's actions were sexual in nature. Interviews with various staff members, including the Administrator, confirmed that no comprehensive investigation was conducted. The Administrator acknowledged awareness of the incident but did not believe an investigation was necessary due to Resident #118's cognitive impairment. Multiple staff members, including CNAs, an LPN, and the Life Enrichment Director, confirmed they were not interviewed or asked to provide statements regarding Resident #118's behaviors. The lack of a thorough investigation into the incident constitutes a deficiency in the facility's handling of alleged sexual abuse cases.
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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