Twin Oaks Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Laplace, Louisiana.
- Location
- 506 West 5th Street, Laplace, Louisiana 70068
- CMS Provider Number
- 195303
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Twin Oaks Nursing Home during CMS and state inspections, most recent first.
The facility failed to timely report an injury of unknown source with serious bodily injury to the State Survey Agency as required by its abuse and incident reporting policy. A resident with cognitive impairment, upper and lower extremity limitations, and dependence on staff for transfers and ADLs complained of left shoulder pain, and an NP ordered an x-ray that showed an age-indeterminate proximal humerus fracture with displacement, later described by the physician as an acute displaced angulated fracture. Despite the resident’s condition and the unclear origin of the injury, the Administrator and DON concluded the injury was not of unknown origin based on the resident’s osteoporosis diagnosis, did not suspect abuse, and did not report the incident through the State Incident Management System within the required 2-hour window, resulting in delayed reporting to the State Survey Agency.
A resident's room was found to have a strong unpleasant odor, soiled linens left on a bed, a spill near the door, and debris scattered on the floor. These conditions were confirmed by a CNA and acknowledged by the DON as not meeting required standards for cleanliness and comfort.
A resident's nebulizer tubing was not changed and dated weekly as required by physician orders and facility policy. Observations showed the tubing was dated over a month prior, and staff interviews confirmed it should have been changed weekly but was not.
A menu substitution was made for a meal, replacing brussel sprouts with beets, without documentation or approval from the RD. The dietary manager did not notify the RD of the change, and there was no evidence that the required approval process was followed.
Surveyors identified that food items in the facility's refrigerator and freezer were not properly dated or covered, and some items from outside sources were not labeled as required. Additionally, expired sanitization test strips were found in use for the dishwasher, with staff confirming these practices did not meet facility policy.
The facility did not provide written notification to the State's LTC Ombudsman for the discharge of two residents, as required. Documentation review showed that the necessary notifications were not present in the residents' records.
A facility-wide assessment did not include documentation addressing the behavioral health needs of the resident population, staff competencies related to behavioral health, or necessary facility resources, despite 42 residents being identified with such needs. This deficiency was confirmed by the administrator during the survey.
A resident was struck in the face by another resident, resulting in a swollen upper lip, as witnessed by a CNA and documented by an RN. Despite clear evidence of physical harm, facility staff did not classify the incident as abuse, contrary to facility policy.
The facility did not report a physical altercation between two residents, where one sustained a swollen upper lip after being struck, to the statewide incident management system as required. Despite a CNA witnessing the event and documentation of injury, the administrator did not consider the incident abuse and failed to make the mandated report.
A resident with a new diagnosis of bipolar disorder was not referred for a required PASARR Level II evaluation. Despite documentation of the new diagnosis in the psychiatric assessment, there was no evidence that the facility initiated a referral or completed the necessary screening, as confirmed by the social worker.
A resident was found with gauze and a ketchup packet in his throat after a drop in blood pressure led to a hospital visit. The facility's investigation was incomplete, failing to interview key staff and a fellow resident present during the incident. The administrator acknowledged inaccuracies in the report regarding the resident's wound care orders.
The facility failed to provide adequate nail care for two residents with hemiplegia, as their nails were observed extending past the tips of their fingers and toes. Despite care plans indicating the need for assistance with ADLs, including grooming, there was no documented evidence of nail trimming for one resident over a two-week period. Staff confirmed the need for nail care, highlighting a deficiency in maintaining residents' cleanliness and grooming.
A resident was observed receiving oxygen therapy at varying levels without a physician's order or a developed care plan. Despite being cognitively intact, the resident's care plan lacked documentation for their oxygen therapy. Interviews with nursing staff confirmed the absence of necessary orders and care planning.
The facility failed to ensure nursing staff signed off on medication counts at shift changes for two medication carts, as required by their Controlled Substances Policy. Interviews confirmed that LPNs did not document narcotic counts, and the DON acknowledged the oversight.
A resident's confidentiality was breached when a sign detailing their dialysis schedule was posted on their door, visible to anyone in the hallway. An LPN recognized this as a HIPAA violation, and the DON confirmed the sign should not have been displayed.
A facility failed to complete a correct Level 1 PASARR for a resident with Major Depressive Disorder, Anxiety, and Schizophrenia, who was receiving daily antipsychotics. Despite these diagnoses, no referral was made for a Level II PASARR evaluation. This error was acknowledged by the facility's social services staff.
A resident was not referred for dental services despite having a care plan that included dental appointments and periodic visits. The resident, who had significant dental issues, was not listed on the facility's dental treatment schedule, and there was no documented evidence of a dental evaluation. Observations showed the resident had no upper teeth and grey-colored bottom teeth, and the resident expressed difficulty in chewing and a need for dental care. Facility staff confirmed the oversight.
The facility failed to maintain infection control by storing clean mop heads in a contaminated laundry area and not ensuring proper PPE and hand hygiene during incontinence care for a resident on Enhanced Barrier Precaution. A CNA did not wear a gown or perform hand hygiene between glove changes, as confirmed by the Assistant Director of Nursing.
A resident with Alzheimer's and other conditions alleged that the nursing home administrator pushed her, an incident documented in a police report and a Physician's Emergency Certificate. Despite the resident informing the police and facility staff, the allegation was not reported to the state agency as required. Interviews revealed that the regional administrator was unaware of the incident until later, and the Director of Nursing did not report it to corporate management.
A resident alleged that an administrator pushed her, but the facility failed to investigate the claim as required by its policy. Despite the resident's statement being documented in a police report, there was no evidence of an investigation, and interviews confirmed the lack of action.
The facility failed to provide documented training for the Administrator in essential areas such as QAPI, behavioral health, ethics, and resident rights. This deficiency was confirmed by the Regional Administrator, who acknowledged the absence of training documentation.
The facility failed to protect residents from verbal and physical abuse by other residents. Incidents included a resident striking another in the face, a verbal and physical altercation between two residents, a resident hitting another in the head, a resident slapping another, and a resident verbally threatening another. These incidents were witnessed by staff and confirmed by the Administrator.
The facility failed to report an allegation of resident-to-resident abuse and did not report incidents of physical abuse in a timely manner. A resident verbally threatened another, and two incidents of physical abuse were reported past the required 2-hour mark. The administrator confirmed the delays and indicated she was solely responsible for reporting.
The facility failed to investigate an incident of verbal abuse between two residents, both with moderate cognitive impairment. Despite the incident being discussed in a leadership meeting, no investigation was conducted, as confirmed by the facility's administrator.
Failure to Timely Report Injury of Unknown Source with Serious Bodily Injury
Penalty
Summary
The facility failed to timely report an injury of unknown source with serious bodily injury to the State Survey Agency as required by its Abuse, Neglect, and Misappropriation of Funds Program policy. The policy stated that if abuse was determined, could not be ruled out with reasonable certainty, or if the source of an injury was unknown and could not be determined, the Administrator would report the incident through the State Incident Management System. An incident report submitted through the State Incident Management System showed that an injury of unknown origin with bruising to the left shoulder was reported for Resident #1 on 12/16/2025 at 4:15 PM, and that the resident had reported this issue the week prior. Nursing documentation showed that on 12/09/2025 at 9:42 AM, the resident complained of pain to the left shoulder. Resident #1’s quarterly MDS with an Assessment Reference Date of 12/09/2025 documented that the resident was not interviewable or was confused (BIMS score of 99), had upper and lower extremity impairments, and was dependent on staff for transfers and ADLs. A nurse practitioner was notified on 12/11/2025 that the resident complained of left shoulder pain and ordered an x-ray. The radiology report dated 12/11/2025 revealed an age-indeterminate fracture of the proximal left humerus with mild displacement, and a physician progress note dated 12/16/2025 described an acute displaced angulated fracture through the surgical neck of the humerus with medial displacement of the shaft. The Administrator and the DON each stated they determined the injury was not of unknown origin based on the resident’s osteoporosis diagnosis and did not suspect abuse; therefore, they did not report the incident to the State Survey Agency within the required two-hour timeframe.
Resident Room Not Maintained in Clean and Homelike Condition
Penalty
Summary
Surveyors observed that one resident's room was not maintained in a safe, clean, and comfortable condition as required. The room had a strong unpleasant odor, and soiled linens with an odor were piled on the roommate's bed. Additionally, there was a small puddle of an unknown liquid by the door, and the floor was scattered with small pieces of paper, a straw, and other white debris. These findings were confirmed by a CNA during an interview, who acknowledged the presence of the odor, soiled linens, trash, debris, and the spill. The DON also confirmed these observations and acknowledged that the room should not have been in that state. No information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Change and Date Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to ensure that respiratory nebulizer tubing for a resident was changed and dated according to physician orders and facility policy. Specifically, the physician's orders required that all respiratory tubing, supplies, and storage bags be changed and dated every Sunday during the overnight shift. However, multiple observations over several days revealed that one resident's nebulizer tubing was dated more than a month prior and had not been changed as required. Interviews with two LPNs and the DON confirmed that the tubing should be changed weekly, and the DON acknowledged that the tubing had not been changed since the date indicated on the tubing, which was several weeks past due. The deficiency was identified through direct observation, record review, and staff interviews.
Menu Substitution Not Approved by Registered Dietician
Penalty
Summary
The facility failed to ensure that menu substitutions were approved by the registered dietician as required. On 08/11/2025, the approved lunch menu included white beans, ham, steamed rice, and brussel sprouts, but the meal served consisted of white beans, rice, and beets. The dietary manager did not document the substitution of beets for brussel sprouts and did not notify the registered dietician for approval of this change. Interviews with the dietary manager and administrator confirmed that the substitution was neither documented nor communicated to the registered dietician, who also confirmed he was not notified. There was no documented evidence to show that the registered dietician was informed of or approved the menu revision.
Deficient Food Storage, Labeling, and Sanitization Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and safety practices. Food items stored in the three-door refrigerator and freezer, including disposable bowls of dry cereal, a partially used container of frozen chicken liver, and cups of a pudding-like substance, were found to be undated and, in some cases, uncovered. Staff interviews confirmed that these items should have been labeled with an opened date and covered as per facility policy. Additionally, food items from outside sources, such as a bottle of frozen hydrate alkaline water and an electrolyte drink, were stored in the facility's freezer without proper labeling to indicate their origin, contrary to the facility's policy of only accepting food from approved suppliers. Further, the facility was found to be using expired sanitization test strips for its low-temperature dishwasher, with the expiration date having already passed. Staff confirmed that these expired strips should not have been in use. These findings were based on direct observations and staff interviews, and the facility's own policies were reviewed to confirm the requirements for food storage, labeling, and sanitization monitoring.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide written notification to the State's Long-Term Care Ombudsman regarding the discharge of two residents. Record reviews and interviews confirmed that one resident was discharged on 03/05/2025 and another on 01/11/2025. There was no documented evidence that the Ombudsman was notified in writing of either discharge, as required. This deficiency was identified through review of the electronic medical records and the absence of corresponding notification documentation.
Facility-Wide Assessment Lacks Behavioral Health Considerations
Penalty
Summary
The facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required. Record review showed that 42 residents were identified as having behavioral health needs. However, the facility's most recent facility-wide assessment, last revised in September 2024, did not contain any documented evidence that it addressed the behavioral health needs of the resident population, staff competencies related to those needs, or the facility resources necessary to care for residents with behavioral health needs. This deficiency was identified for three sampled residents reviewed for behavioral health needs. During an interview, the administrator confirmed these findings.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. According to the facility's policy, abuse includes the willful infliction of injury resulting in physical harm. Documentation in the electronic medical record showed that a resident complained of pain and was found to have a swollen upper lip after being struck in the face by another resident. A certified nursing assistant witnessed the incident and confirmed that the resident was repeatedly hit in the face. Despite these findings, interviews with facility staff, including a quality assurance nurse and the administrator, revealed that they did not consider the incident to be physical abuse. The quality assurance nurse stated that the altercation was not abuse because the aggressor was reacting to the other resident digging in his bag. The administrator also did not classify the event as abuse, even though physical harm was observed and documented.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the statewide incident management system (SIMS) as required by policy. According to the facility's policy, any incident where abuse is determined or cannot be ruled out must be reported to the state surveying agency. Documentation showed that one resident complained of pain and was found to have a swollen upper lip after being hit by another resident. A CNA witnessed the incident, observing one resident repeatedly hitting another in the face. Despite these findings, the administrator did not consider the event to be abuse and did not report it to SIMS, as confirmed during an interview.
Failure to Refer Resident for PASARR Level II After New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of bipolar disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. The resident was initially admitted with a Level I PASARR approved for a temporary period and later received another Level I PASARR screening indicating Level II services were not required. However, after a psychiatric assessment documented a new diagnosis of bipolar disorder, there was no evidence in the electronic medical record that a Level II PASARR screening was completed or that a referral was made to the appropriate state agency. The facility's social worker confirmed in an interview that no new referral for a Level II PASARR screening was made following the new diagnosis.
Incomplete Investigation of Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident who was found with gauze and an empty ketchup packet lodged in his throat after being sent to the hospital due to a drop in blood pressure. The facility's policy requires evidence of a thorough investigation for all alleged violations, but the investigation into this incident was incomplete. The facility's report speculated that the gauze was obtained during emergency transport or at the hospital, despite the resident having an active wound care order for gauze application to his knee. The facility's camera footage was reviewed, but it was out of focus, and the facility did not interview all potential witnesses present during the incident. Key staff members and a resident who were present during the lunch meal service when the incident occurred were not interviewed by the facility's administrative staff. The housekeeper, dietary aide, and another resident who shared the table with the affected resident were not questioned or asked to provide statements about their observations. The administrator confirmed the lack of interviews and acknowledged that the facility's report inaccurately stated that the resident did not have wound care orders. This oversight in the investigation process led to a deficiency in addressing the allegation of neglect properly.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were admitted with diagnoses of hemiplegia affecting one side of their bodies. Resident #28, who had impairment on one side of her upper and lower extremities, was observed on two occasions with toenails and fingernails extending past the tips of her nailbeds. This observation was confirmed by both a Certified Nursing Assistant (CNA) Supervisor and a Wound Care Nurse, who acknowledged that the resident's nails needed trimming. The resident's care plan indicated a requirement for assistance with activities of daily living (ADLs), including maintaining cleanliness and grooming, which was not adhered to in this instance. Similarly, Resident #40, who also had a self-care deficit due to right side hemiplegia, was observed with nails extending past the tips of his fingers on two separate occasions. A review of his ADL records showed no documented evidence of nail trimming over a two-week period. The Director of Nursing confirmed the need for nail trimming during an interview. Both residents' care plans emphasized the importance of being kept clean, dry, and well-groomed, yet the facility failed to meet these care requirements, resulting in the identified deficiency.
Lack of Care Plan for Resident's Oxygen Therapy
Penalty
Summary
The facility failed to develop a plan of care for a resident receiving respiratory care by nasal cannula. Observations revealed that the resident was receiving oxygen at varying levels, initially at 2 liters per minute (LPM) and later at 4 LPM, without a corresponding physician's order. The resident's Minimum Data Set indicated they were cognitively intact, yet there was no documented plan of care for their oxygen therapy. Interviews with the Licensed Practical Nurse and the Assistant Director of Nursing confirmed the absence of a physician's order for the resident's oxygen care. Additionally, the Director of Nursing acknowledged that no care plan had been developed for the resident's oxygen therapy.
Failure to Document Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for two medication carts. This deficiency was identified through record reviews and interviews, revealing that the facility's Controlled Substances Policy was not adhered to. The policy requires that controlled drugs be counted at the end of each shift by both the nurse coming on duty and the nurse going off duty, with any discrepancies reported immediately to the Director of Nursing (DON) or designee. However, documentation of these counts and signatures was missing for numerous shifts across two medication carts over several months. Interviews with nursing staff confirmed the lack of compliance with the policy. For instance, an LPN admitted to not signing the narcotics book after completing the narcotic count with the nurse going off duty. The DON also acknowledged that narcotic counts were not documented as required on the specified dates. This lack of documentation and adherence to the policy indicates a failure in the facility's process for ensuring the accurate dispensation of controlled medications.
Resident Confidentiality Breach Due to Improper Signage
Penalty
Summary
The facility failed to protect the confidentiality of a resident's medical information, specifically for one resident out of a sample of 32. During an observation, it was noted that a sign titled 'Appointment Sheet' was posted on the exterior side of the resident's door facing the hallway. This sign included the resident's name and detailed their dialysis schedule, indicating pick-up times. In an interview, an LPN acknowledged that this was a violation of the Health Insurance Portability and Accountability Act (HIPAA), as it exposed the resident's medical condition, end-stage renal disease, to anyone passing by. The Director of Nursing confirmed that such a sign should not have been posted on the door.
Failure to Complete Correct PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed correctly for a resident diagnosed with Major Depressive Disorder, Anxiety, and Schizophrenia. The resident was admitted with these diagnoses and was receiving antipsychotics daily. A review of the resident's Minimum Data Set (MDS) indicated these mental health conditions, yet the Level 1 PASARR completed earlier did not result in a referral to the appropriate state-designated authority for a Level II PASARR evaluation and determination. This oversight was confirmed during an interview with the facility's social services staff, who acknowledged that the Level 1 PASARR was completed incorrectly and that a Level II PASARR should have been requested.
Failure to Refer Resident for Dental Services
Penalty
Summary
The facility failed to ensure that a resident was referred for dental services, as evidenced by the case of Resident #25. The resident was admitted on an unspecified date and had a care plan with a goal date of 08/21/2024, which included approaches for arranging dental appointments and periodic dental visits due to the potential for dental issues. However, there was no documented evidence that Resident #25 was evaluated for dental services, and the resident was not listed on the facility's dental treatment schedule dated 08/19/2024. Observations on 08/05/2024 revealed that Resident #25 had no upper teeth, only front bottom teeth, and the remaining bottom teeth were grey in the middle. During an interview, the resident expressed the need to see a dentist, mentioning difficulty in chewing food and a desire to prevent further tooth loss. Interviews with facility staff confirmed the lack of documentation and evaluation for dental services for Resident #25.
Infection Control Deficiencies in Laundry and Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. Firstly, clean mop heads were improperly stored in the contaminated laundry area, directly above soiled linen barrels. This was observed on two separate occasions, and both the Laundry Supervisor and the Administrator confirmed the inappropriate storage of clean mop heads in the contaminated area. Secondly, the facility did not ensure that staff adhered to proper hand hygiene and personal protective equipment (PPE) protocols during incontinence care for a resident with a diabetic ulcer on Enhanced Barrier Precaution (EBP). A Certified Nursing Assistant (CNA) was observed performing incontinence care without wearing a gown and failing to perform hand hygiene between glove changes. The CNA acknowledged the lapse in protocol, and the Assistant Director of Nursing confirmed the expected procedures were not followed.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse involving a resident to the required state survey agency. The incident involved a resident who was admitted with diagnoses including Alzheimer's disease, schizophrenia, depressive disorder, dementia, and anxiety. The resident alleged that the nursing home administrator pushed her, an incident that was documented in a Physician's Emergency Certificate and a police report. Despite the resident informing the police and facility staff about the incident, the allegation was not reported to the state agency as required by the facility's policy. Interviews conducted during the investigation revealed that the resident's responsible party and the facility's Ombudsman were informed of the incident. The nursing home administrator initially acknowledged the report but later denied the interview, claiming inconsistency in reporting the source of information. The regional administrator confirmed that he was unaware of the allegation until the day of the interview and verified that the incident was not reported to the state agency. Additionally, the Director of Nursing was aware of the allegation but did not report it to corporate management, further contributing to the failure to report the incident as required.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of physical abuse involving a resident. According to the facility's policy titled 'Policy for Prohibition of Abuse, Neglect and Misappropriation of Property,' all alleged violations of abuse must be thoroughly investigated. However, there was no documented evidence that the allegation made by a resident, who claimed that the administrator pushed her, was investigated. The police report confirmed the resident's statement, yet the facility did not present any documentation of an investigation. Interviews with the administrator and the regional administrator confirmed that the allegation was not investigated.
Lack of Documented Training for Administrator
Penalty
Summary
The facility failed to implement an effective training program for its staff, as evidenced by the lack of documented training for the Administrator. The Administrator, hired on 07/22/2015, did not have documented evidence of receiving training in key areas such as Quality Assurance and Performance Improvement (QAPI), behavioral health, ethics, and resident rights. This deficiency was confirmed during an interview with the Regional Administrator, who acknowledged the absence of documentation for these essential trainings.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents. This deficiency was identified for six residents. Resident #3 struck Resident #4 in the face in the dining room, witnessed by the Food and Nutrition Manager and confirmed by the Administrator through video review. Resident #5 and Resident #6 were involved in a verbal and physical altercation in the hallway, with Resident #6 being verbally abusive and Resident #5 shoving Resident #6 into a clothing cart. The incident was witnessed by the Laundry Supervisor and confirmed by the Administrator. Resident #7 hit Resident #8 in the head in the dining room, witnessed by another resident and confirmed by video review. Resident #2 slapped Resident #9 in the dining room, witnessed by the Treatment Nurse and confirmed by the Administrator. Resident #1 verbally abused Resident #10, threatening to kill him if he didn't shut up, which was confirmed by the Administrator and an LPN. These incidents indicate a failure to protect residents from abuse by other residents, as required by regulations.
Failure to Report Abuse Timely
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident abuse was reported to the State Survey Agency. Specifically, Resident #1 verbally threatened Resident #10, and this incident was discussed in a leadership meeting but was not reported to the state agency as required. The incident was documented in a nurse's note, and the LPN on duty acknowledged that an incident report should have been written but was not. The administrator confirmed that a State Incident Management Systems (SIMS) report should have been filed but was not completed. Additionally, the facility failed to report incidents of physical abuse in a timely manner for two residents. An incident involving Resident #6 was discovered and reported to SIMS past the required 2-hour mark. Similarly, an incident involving Resident #9 was also reported to SIMS beyond the 2-hour reporting window. The administrator confirmed the delayed reporting times and indicated that she was the only one with access to SIMS and responsible for reporting.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of verbal abuse between two residents. Resident #1, who has a history of moderate cognitive impairment and various medical conditions, was documented in the nurses' notes as having shouted a threatening remark at Resident #10. Resident #10 also has moderate cognitive impairment and exhibits frequent physical and verbal behavioral symptoms directed toward others. Despite the incident being discussed in a Morning Leadership Meeting, there was no evidence that an investigation was conducted. The deficiency was confirmed during an interview with the facility's administrator, who acknowledged that the incident constituted resident-to-resident abuse and that an investigation should have been conducted but was not. The facility failed to provide any evidence of an investigation into the verbal abuse incident, indicating a lapse in their protocol for handling such allegations.
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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