Citations in Louisiana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Louisiana.
Statistics for Louisiana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Louisiana
A resident with moderate hearing impairment and intact cognition, care planned as needing hearing aids, did not receive appropriate assistive devices after the facility failed to follow up with community resources. Social services knew the resident could not afford a hearing program’s application fee and that referrals had been made by an ENT to outside providers for assistance with hearing devices, including an evaluation that was never scheduled. Despite this and the facility policy assigning social services responsibility for obtaining outside services, the Social Services Director did not follow up with the community providers or seek alternative assistance after family involvement lapsed, leaving the resident waiting for hearing aids for months.
Two residents with cognitive and psychiatric conditions engaged in repeated physical altercations on consecutive days after an accusation of stolen soda. On the first day, a resident using a walker accused a wheelchair user of theft, after which the wheelchair user rammed the walker and struck the other resident's leg while a CNA was pushing her away. On the next day, the resident with the walker kicked the wheelchair user in the leg as she passed in the hallway, later admitting she did so in retaliation for the prior day's incident. An LPN documented both events, and the administrator was notified, but the facility did not effectively prevent or protect the residents from physical abuse by each other, contrary to its abuse prevention policy.
A resident was discharged from the facility without a required discharge summary being completed, contrary to the facility’s own policy that mandates a discharge summary and post-discharge plan for anticipated discharges to a private residence or another nursing care facility. Record review showed the absence of any discharge summary in the resident’s medical record, and the SSD confirmed during interview that no discharge summary had been completed.
A resident with morbid obesity, vascular dementia, and an above-the-knee amputation, who was cognitively intact and dependent on a mechanical lift with two-person assist for transfers, was not assisted out of bed over a weekend despite repeatedly requesting to get up. CNAs and an LPN reported that lifts on the resident’s hall and other halls were not working or had uncharged batteries, resulting in residents who required lifts not being gotten out of bed. The resident’s responsible party stated the resident had been reporting ongoing difficulty getting out of bed due to lift problems, and administration later acknowledged there had been lift issues, while also confirming staff should have used a working lift to honor the resident’s request to get out of bed.
A cognitively intact resident, identified on the facility’s smoker list as an unsafe smoker, was denied the ability to smoke during nighttime hours because they were not on the facility’s safe smoker list, despite a policy stating residents have the right to smoke and that cognitively impaired or mobility-limited residents may smoke with staff supervision. The resident reported being refused nighttime smoking, an LPN confirmed the resident was not on the list allowing smoking after extended hours, and reception staff stated that unsafe smokers were not permitted to go outside at night and acknowledged they had previously denied this resident’s requests to smoke during those hours, contrary to the DON’s description of how unsafe smokers should be supervised.
A resident with moderate cognitive impairment was found with medications left unsecured at the bedside, contrary to the facility’s medication storage policy requiring locked compartments and restricted access to drugs. Surveyors observed a split white pill on the floor next to a labeled medication cup and another labeled cup containing a pill on the bedside table. An LPN confirmed the medications had been left in the room, acknowledged the resident did not have the capacity to self-administer medications, and stated they should not have been left at the bedside; the DON also acknowledged that the medications were improperly left in unlocked, unattended cups.
A resident with stage 4 CKD had a physician-ordered renal diet specifying no potatoes, which was reflected on the meal ticket. However, the resident was observed being served cubed potatoes. An LPN acknowledged this conflicted with the renal diet, and the DON explained that the process requires dietary staff to follow the meal ticket and floor staff to verify trays against diet orders, confirming the resident should not have received potatoes.
Staff failed to follow hand hygiene and glove-change requirements during incontinence care for a resident. Two CNAs removed a soiled brief, cleansed the buttocks and perineal area, and then proceeded to apply a clean brief, reposition the resident, place a clean draw sheet, and handle clean linens and room furnishings without changing gloves or performing hand hygiene, despite facility policy and CDC guidelines requiring hand decontamination when moving from contaminated to clean body sites. Both CNAs later acknowledged they should have changed gloves and performed hand hygiene, and the DON confirmed this expectation.
The facility did not administer influenza and pneumococcal vaccines to a resident despite signed consents from the responsible party and a facility policy requiring vaccination unless contraindicated or refused. The resident, who had moderately impaired cognition, expressed a desire to receive both vaccines, and the responsible party confirmed consent had been given. Review of the clinical record showed no documentation of vaccine administration, and the ADON/Infection Preventionist, DON, and Administrator all acknowledged there was no evidence the vaccines had been provided.
The facility failed to ensure antidiabetic medications were administered per physician orders for three residents with diabetes. One resident with type 2 DM did not receive multiple ordered morning doses of Lantus insulin, as confirmed by eMAR review and an LPN interview. Another resident with diabetes mellitus without complications missed a scheduled weekly Ozempic injection, which the responsible LPN acknowledged was not given. A third resident with type 2 DM missed numerous ordered morning doses of Humulin 70/30 insulin, with two LPNs confirming they did not administer the medication on the identified days, and the DON confirming that all three residents should have received their medications as ordered.
Failure to Follow Up on Community Resources for Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities by not following up with community resources. The resident, who was cognitively intact with a BIMS score of 13 and had moderate hearing difficulty requiring increased volume and distinct speech, had a care plan problem for altered communication related to being hard of hearing and recurrent cerumen impaction, with a noted need for hearing aids. The care plan documented that paperwork for hearing aids had been sent with the family but not returned due to financial issues. In an interview, the resident reported having waited months for hearing aids and stated the facility told her they were waiting on a company to get the devices, while the surveyor had to speak very loudly for the resident to hear. Record review and interviews with the Social Services Director (SSD) showed that the resident had been seen by an ENT specialist and was recommended for a hearing program that required an application fee the resident could not afford. The SSD documented that the ENT office stated the resident could not participate in the program without paying the fee and that the resident was referred to another community provider for assistance with hearing devices. The SSD later learned that this community provider saw the resident and referred her to a second provider for an evaluation to assist with obtaining hearing aids, but the evaluation was never scheduled. The SSD acknowledged she did not follow up with either community provider after communication with the family ceased and did not pursue other assistance or resources for hearing aids from that time until questioned by the surveyor, despite facility policy assigning social services responsibility for making referrals and obtaining needed services from outside entities.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during resident-to-resident altercations on consecutive days. Facility policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse, and that administration will protect residents from abuse by anyone, including other residents, and protect residents during abuse investigations. Despite this policy, one cognitively intact resident with bipolar disorder and depression with psychotic features (Resident #81) and another resident with Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder (Resident #2) engaged in physical aggression toward each other without effective prevention of further contact. On the first day, documentation and interviews showed that Resident #81 was walking in the hallway with a walker when Resident #2, in a wheelchair, passed by. Resident #81 accused Resident #2 of stealing her soda, and Resident #2 then ran her wheelchair into Resident #81's walker. A CNA intervened and began pushing Resident #2 back to her room, during which Resident #2 reached out and hit Resident #81 on the leg. Nursing notes and the facility incident report documented that both residents were then taken to their rooms and that no injuries were observed at that time. The LPN and CNA interviews were consistent in describing that Resident #2 physically struck Resident #81 during the separation. On the following day, the same LPN documented that Resident #2 was again propelling herself in the hallway when Resident #81 came out of her room and kicked Resident #2 in the leg as she passed. Resident #2 yelled out in response, and when questioned, Resident #81 admitted to kicking Resident #2, stating she did so because Resident #2 had hit her the previous day and stolen her soda and that she was not sorry. The LPN assisted Resident #2 back to her room while Resident #81 remained in her room to finish breakfast. The administrator confirmed being notified of both physical altercations at the times they occurred and that there were no injuries, but the incidents demonstrated that the facility did not effectively protect either resident from physical abuse by the other resident as required by its abuse prevention policy.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for one of three closed records reviewed. The facility’s policy, last reviewed on 04/09/2025, states that when a discharge is anticipated to a private residence or another nursing care facility, a discharge summary and post-discharge plan must be developed to assist the resident’s adjustment, and that a copy of the discharge summary must be provided to the resident, the receiving facility, and filed in the resident’s medical record. Record review showed that Resident #123 was admitted on an unspecified date and discharged on 11/07/2025, but the medical record contained no documentation of a completed discharge summary. During a record review and interview on 01/28/2026 at 2:06 p.m., the Social Services Director confirmed that the resident had been discharged on 11/07/2025 and further confirmed that a discharge summary was not completed for this resident. No additional medical history or condition details for the resident at the time of discharge were documented in the report.
Failure to Honor Resident Choice Due to Unresolved Lift Equipment Issues
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and resident choice regarding when to get out of bed for one cognitively intact resident who was dependent on staff and mechanical lifts for transfers. The resident, admitted with multiple diagnoses including unspecified atrial flutter, type 2 diabetes mellitus, morbid obesity, hypertensive heart disease, vascular dementia, and an above-the-knee left leg amputation, had a care plan indicating an ADL self-care performance deficit requiring use of a lift system with a brown sling and assistance of two staff for transfers. Despite this, over a specified weekend the resident reported being left in bed after repeatedly asking to get up and being told there were no lift pads available or that the lift was not working. Multiple staff interviews confirmed that lifts on the resident’s hall were reportedly not working during that weekend, and that residents requiring lifts, including this resident, were not gotten out of bed due to lift issues and problems with keeping batteries charged. One CNA stated she attempted to obtain a lift from other halls but found those lifts also not working, and another CNA reported that at times only one lift in the building was working and that the resident typically did not get out of bed when lift problems occurred. An LPN acknowledged knowing the resident did not get out of bed that weekend and heard the resident state he expected to get up on Monday. The resident’s responsible party reported receiving calls from the resident over the preceding weeks about difficulty getting out of bed due to lift problems and was later informed by administration that there had been lift issues. The administrator stated he had been aware of lift issues earlier in the week and had maintenance check all lifts, batteries, and charging ports, but he was not informed of lift problems on the specific weekend in question, and confirmed that if the resident had requested to get out of bed, staff should have used a working lift.
Failure to Honor Resident’s Right to Smoke per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to smoke in accordance with its own Resident Smoking and Tobacco Use Policy. The policy, effective 08/01/2025, stated that residents had the right to smoke, and that residents who were cognitively impaired or had mobility limitations could only smoke under staff supervision, with staff responsible for monitoring compliance. Resident #6’s Quarterly Minimum Data Set dated 12/26/2025 showed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Despite this, the facility’s undated list of smokers identified Resident #6 as an unsafe smoker. Resident #6 reported on 01/22/2026 that he was not allowed to go outside to smoke at night because he was not on the list permitting smoking after 7:00 PM. An LPN confirmed that Resident #6 was not on the list of smokers allowed to smoke past the extended hours of 7:00 AM to 8:00 PM. The DON stated that the security guard, evening receptionist, and/or night receptionist were responsible for supervising unsafe smokers who wanted to smoke outside the 7:00 AM to 7:00 PM timeframe. However, two receptionists reported that unsafe smokers were not allowed to go outside to smoke at night and that only residents on the safe smoker list could go out during those hours. Both receptionists acknowledged they had previously refused Resident #6 the ability to smoke at night because he was not on the safe smoker list, resulting in the resident being denied the right to smoke during nighttime hours.
Medications Left Unsecured at Bedside of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments and accessible only to authorized personnel, resulting in a resident having medications left at the bedside. The facility’s undated Storage of Medications policy stated that medications were to be stored in locked compartments, in their original packaging, and that only persons authorized to prepare and administer medications should have access to them. Review of a quarterly MDS for Resident #47, with an Assessment Reference Date of 10/29/2025, showed a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. During observation of Resident #47’s room on 01/21/2026 at 12:40 PM, surveyors noted a white pill on the floor split in two next to a medication cup labeled with Resident #47’s name, and a second medication cup, also labeled with the resident’s name, containing a white pill on the bedside table. In interviews, the LPN confirmed the pills and medication cups were in the resident’s room, stated that the medications should not have been left at the bedside, and reported that the resident did not have the mental capacity to self-administer medications; the DON also acknowledged that the medications should not have been left at the bedside in unlocked, unattended medication cups. These observations and interviews demonstrate that the facility did not follow its own medication storage policy and allowed a moderately cognitively impaired resident unsupervised access to medications in the room, contrary to requirements that only authorized staff have access to drugs and biologicals and that such items be stored in locked compartments.
Failure to Follow Renal Diet Restrictions for Resident with CKD
Penalty
Summary
The facility failed to provide a diet that met a resident's special dietary needs when a resident with a physician-ordered renal diet was served food inconsistent with that order. The facility's undated Nutrition policy stated that all physician-ordered diets were to be implemented promptly and that the dietary department was to prepare and serve meals that met ordered diets and nutritional requirements. The resident's medical record showed a diagnosis of stage 4 chronic kidney disease, and the January 2026 physician's orders specified a renal diet. The resident's meal ticket for 01/21/2026 further specified a renal diet with no potatoes. Despite these orders and documentation, observation on 01/21/2026 at 1:05 PM showed the resident was served cubed potatoes. An LPN immediately acknowledged that the resident should not have been served potatoes per the renal diet. The DON described the facility's process for ensuring correct diets, stating that diet recommendations are placed on the meal ticket, dietary aides are to follow the meal ticket when preparing plates, and floor staff are to check trays against the meal ticket when distributing them, notifying nursing and dietary if inconsistencies are found. The DON confirmed that the resident should not have been served potatoes.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during incontinence care. The facility’s Standard Precautions policy required staff to perform hand hygiene immediately after contact with any resident item that may be contaminated, and CDC guidelines required hand decontamination when moving from a contaminated body site to a clean body site during patient care. During an observation, two CNAs entered a resident’s room to perform incontinence care, removed the resident’s soiled diaper, and wiped the resident’s buttocks and perineal area. After completing care of the contaminated area, the CNAs did not change their gloves or perform hand hygiene before proceeding to place a clean diaper on the resident, roll and reposition the resident, place a clean draw sheet, and cover the resident with clean linen. One CNA then opened and closed the resident’s dresser door and raised the head of the bed while still wearing the contaminated gloves, without performing hand hygiene or changing gloves. In subsequent interviews, both CNAs acknowledged they had not changed gloves or performed hand hygiene after removing the soiled diaper and stated they should have done so. The DON confirmed that the CNAs should have changed gloves and performed hand hygiene when moving from a contaminated body area to a clean body area during incontinence care.
Failure to Administer Influenza and Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were administered in accordance with its own policy for one resident. The facility’s undated Influenza and Pneumococcal Vaccine policy stated that residents should be vaccinated against pneumococcal disease and influenza unless medically contraindicated or refused by the resident or legal representative. Resident #60’s Minimum Data Set, with an Assessment Reference Date of 01/07/2026, showed the resident was admitted on 07/02/2025 and had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. Review of the clinical record on 01/20/2026 revealed no documented evidence that the resident had received either the influenza or pneumococcal vaccines. Further record review showed that on 07/02/2025, the resident’s responsible party had signed consent forms for both the pneumococcal and influenza vaccines. In an interview, the resident stated he wanted the influenza and pneumococcal vaccines but had not received them, and the responsible party confirmed she had consented for the vaccines and was unsure if they had been given. The Assistant DON/Infection Preventionist reported that the facility had no evidence the resident received either vaccine since admission. The DON and the Administrator both acknowledged in interviews that the resident had not received the influenza or pneumococcal vaccinations prior to 01/21/2026 and that the resident should have received them.
Failure to Administer Ordered Antidiabetic Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders for three residents with diabetes. Resident #1 had an order for Lantus 26 units subcutaneously twice daily at 8:00 AM and 8:00 PM, starting 08/19/2025. Review of the December 2025 eMAR showed no documented evidence that the 8:00 AM Lantus dose was given on 12/11, 12/12, 12/16, 12/17, 12/18, 12/19, 12/22, and 12/25. The January 2026 eMAR likewise showed no documented evidence of the 8:00 AM Lantus dose on 01/01, 01/02, 01/05, 01/06, 01/08, and 01/12. In an interview, the LPN (S3) stated she did not administer Resident #1’s Lantus on the dates noted, and the DON (S1) confirmed that the Lantus had not been administered as ordered and should have been. Resident #2 had a diagnosis of diabetes mellitus without complications and a physician’s order for Ozempic 0.25 mg subcutaneously once weekly on Friday mornings, starting 12/12/2025. The January 2026 eMAR showed the Ozempic dose was not administered on the scheduled morning, 01/02/2026, and S3 LPN confirmed in interview that she did not administer the medication; S1 DON stated the resident should have received Ozempic as ordered. Resident #3, with type 2 diabetes mellitus, had an order for Humulin 70/30, 24 units subcutaneously at 8:00 AM before breakfast, starting 07/07/2024. The December 2025 eMAR showed no documented evidence that the 8:00 AM Humulin 70/30 dose was administered on 12/02, 12/05, 12/16, 12/17, 12/23, 12/26, 12/29, and 12/31, and the January 2026 eMAR showed missing administrations on 01/02, 01/05, 01/06, 01/07, and 01/14. S3 LPN stated she did not administer the Humulin 70/30 on the listed dates except 12/23/2025, and S6 LPN stated she did not administer it on 12/23/2025; S1 DON indicated Resident #3 should have received Humulin 70/30 as ordered.
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