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
Two residents with psychiatric and cognitive conditions engaged in a verbal altercation that escalated when one struck the other in the face with a chair, causing multiple facial fractures. Staff were present and intervened, but the incident resulted in significant injury before separation and assessment occurred. There were no prior documented physical altercations or behavioral changes between the residents.
The facility did not develop care plans that clearly identified whether one or more staff were required to assist with ADLs for several residents with complex medical needs. Despite regular assessments and staff meetings, care plans lacked specific instructions, leaving CNAs without clear guidance on the level of assistance needed for each ADL.
Nursing staff failed to review all discharge documentation and clarify medication orders with the physician, resulting in a resident not receiving prescribed medications, including a necessary home medication, during their stay. The admission orders were based on incomplete information, leading to discrepancies in medication administration.
A resident was transferred to a hospital emergency room and returned, but the required transfer notice was not sent to the State LTC Ombudsman due to missing documentation in both the Emergency Transfer Log and Census Change Sheet. Staff interviews revealed that the responsible LPN was unaware of the requirement to document the transfer, resulting in the omission.
A resident was discharged to a hospital without the required discharge MDS assessment being opened, completed, or transmitted. Both an MDS nurse and the ADON confirmed that the assessment was not done as required.
A resident was physically struck in the face by another resident in the day room, with the incident witnessed by two CNAs and later confirmed by those involved. The facility's investigation substantiated that resident-to-resident abuse occurred, reflecting a failure to protect residents from physical mistreatment as required by policy.
Two residents who required assistance with ADLs did not receive their scheduled showers because CNAs and shower aides were unavailable due to staffing shortages. Both residents, who had intact cognition and documented shower schedules, requested showers but were informed by staff that they could not be accommodated. Staff interviews confirmed that showers were missed when staffing was insufficient, and facility administration was unaware that these residents had not received their scheduled care.
A dumbwaiter cart used to deliver lunch trays was found with dried food residue and had not been cleaned after use, as confirmed by the Dietary Manager. This failure to sanitize the cart between uses was not in accordance with facility policy and professional standards.
Staff did not consistently wear required PPE, such as gowns and gloves, while providing high-contact care to two residents on Enhanced Barrier Precautions for wounds and pressure ulcers. Additionally, shower facilities and equipment were not properly cleaned and disinfected between residents, with visible fecal matter left unaddressed and staff admitting to not using disinfectant after each use, contrary to facility policy.
A resident with multiple mental health diagnoses repeatedly refused hygiene and nail care over several months. Despite staff and hospice documentation of these refusals and notifications to nursing staff, the care plan was not updated to reflect the refusals or include interventions. Staff interviews confirmed awareness of the refusals but acknowledged the care plan did not address them.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual physical harm. Two residents, both with psychiatric and cognitive diagnoses, were sharing a room. One resident, who was cognitively intact, became verbally aggressive with his roommate, who had moderate cognitive impairment. This verbal altercation escalated, and the cognitively impaired resident struck the other in the face with a chair, causing significant facial injuries including orbital and nasal fractures. Prior to this incident, there were no documented physical altercations or behavioral changes between the two residents, and both had a history of verbal arguments but no prior physical aggression. On the day of the incident, staff were present in the hallway and initially intervened to de-escalate a verbal argument between the two residents. After the initial intervention, the residents separated briefly, but the argument resumed. As staff approached to intervene again, the cognitively impaired resident picked up a chair and struck the other resident, also hitting the intervening LPN in the arm. Immediate staff intervention followed, and the residents were separated. The injured resident sustained a skin tear, bruising, and later was found to have multiple facial fractures. The resident initially refused emergency care but was eventually sent to the hospital for evaluation and treatment after imaging revealed the extent of the injuries. The injured resident was assessed multiple times following the incident and consistently denied pain, emotional distress, or fear, and continued to participate in daily activities. Staff interviews confirmed that there were no prior indications or behavioral changes that would have predicted the escalation to physical violence. The incident was witnessed by staff, and immediate action was taken to separate and supervise both residents. The facility's failure to prevent this altercation resulted in significant physical harm to the resident.
Failure to Specify Staff Assistance Levels in ADL Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that clearly identified the required level of staff assistance for activities of daily living (ADLs) for five out of six sampled residents. Medical record and MDS assessment reviews showed that these residents had significant dependencies, including needs for assistance with toileting, personal hygiene, and transfers from bed to chair. However, their care plans did not specify whether one or more staff members were required to assist with each ADL. Interviews with the DON and CNAs confirmed that the care plans lacked this critical information, making it unclear for staff to determine the appropriate level of assistance needed for each resident. The residents involved had complex medical histories, including diagnoses such as dementia, psychosis, hypertensive heart disease, diabetes, pressure ulcers, Alzheimer's, osteoporosis, hypoglycemia, and schizoaffective disorder. Despite regular MDS assessments and weekly meetings to review residents' assistance needs, the facility did not incorporate this information into the care plans. Staff interviews further confirmed that there was no additional assessment tool in use to determine the specific number of staff required for each ADL, and the care plans remained incomplete in this regard.
Failure to Ensure Nursing Staff Competency in Medication Reconciliation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide proper nursing care for one of three sampled residents. Specifically, a nurse did not review the resident's hospital discharge orders when writing admission orders and did not clarify with the physician whether the resident should continue his home medications. The resident was admitted with multiple diagnoses, including surgical aftercare, diabetes with neuropathy, and other chronic conditions. The hospital discharge orders included instructions to continue home medications, such as Pioglitazone 45 mg daily, but did not list Riluzole 50 mg twice daily. However, the admission orders written by the Assistant Director of Nursing (ADON) specified Pioglitazone 30 mg daily and omitted Riluzole entirely. Record review and interviews revealed that the resident and his family brought all home medications to the facility and specifically informed the admitting nurse about the need to continue Riluzole 50 mg twice daily for one month. The nurse took possession of the medications but did not ensure that Riluzole was included in the admission orders or administered during the resident's stay. The resident only discovered the omission upon discharge, when he noticed the Riluzole bottle was still full. The Director of Nursing (DON) and ADON later stated that the medication was not given because it was not on the hospital discharge orders, and the ADON had based admission orders on faxed information rather than the hand-written discharge orders that accompanied the resident. Further interviews confirmed that the admitting nurse did not recall being told about the need to continue Riluzole and did not review the discharge orders that came with the resident. The DON acknowledged that the ADON should have reviewed all discharge documentation and clarified medication orders with the physician, especially regarding the discrepancy in Pioglitazone dosage and the omission of Riluzole. The failure to review all available discharge information and to clarify medication orders resulted in the resident not receiving prescribed medications as intended.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for one of four residents reviewed for admission, transfer, and discharge requirements. Specifically, a resident was admitted to the facility and later transferred to a local hospital emergency room, then returned to the facility. There was no documentation of this transfer in the facility's Ombudsman Emergency Transfer Log or the Census Change Sheet for the relevant month. Interviews with facility staff revealed that the staff member responsible for updating the Emergency Transfer Log did not receive notification of the transfer because the assigned nurse did not complete the Census Change Sheet at the time of the resident's transfer. The assigned nurse confirmed she did not fill out the required documentation and was unaware of the requirement to do so. Facility leadership confirmed that the transfer was not documented as required and that the process for ensuring accurate notification to the Ombudsman was not followed.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and transmitted for one of five residents reviewed for resident assessment. Specifically, a resident was admitted to the facility and later discharged to a local hospital, but a review of the clinical record showed that no discharge MDS assessment was opened, completed, or transmitted as required. During interviews, an MDS nurse and the Assistant Director of Nursing both confirmed that the resident had been discharged and that the necessary discharge assessment had not been initiated or submitted, despite facility policy and regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its own Abuse Recognition, Reporting, and Investigation policy. On the morning of 09/10/2025, one resident entered the day room and struck another resident in the face, an incident witnessed by two CNAs. The physical altercation was later confirmed by both the resident who committed the act and the staff who observed it. The facility's investigation substantiated that resident-to-resident abuse had occurred, indicating a failure to prevent physical mistreatment as outlined in facility policy.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) and Shower Aides provided scheduled showers and baths to two residents who required assistance with Activities of Daily Living (ADLs). Both residents had care plans indicating the need for assistance with bathing, and their shower schedules were documented as occurring on specific days of the week. Despite these plans, neither resident received their scheduled showers on the designated days. Interviews with the residents confirmed that they requested showers as per their routine, but staff informed them that showers could not be provided due to short staffing. Documentation in the residents' records did not show evidence that showers were given on the scheduled days. Staff interviews corroborated the residents' accounts, with CNAs stating that when shower aides were unavailable and staffing was insufficient, not all showers could be completed as scheduled. The facility's administration confirmed that there were multiple CNA call-ins and absences on the days in question, resulting in a shortage of staff. Although duties were redistributed, the administration was not aware that the affected residents had missed their showers. Both residents involved were noted to have intact cognition, and one resident expressed discomfort due to not receiving a shower after exercising.
Failure to Sanitize Dumbwaiter Cart After Use
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen equipment as required by its own policy and professional standards. During an observation and interview with the Dietary Manager, a dumbwaiter cart used to deliver lunch trays was found outside the kitchen door with multiple dried clumps of yellow and brown food matter, as well as dried thin layers of yellow food residue on several shelves. The Dietary Manager confirmed that the cart had been used to deliver lunch trays that day and acknowledged that it should have been cleaned after each use. She further stated that, based on the condition of the cart, it had not been cleaned after the last meal or the previous night, contrary to facility policy which requires sanitization of the dumbwaiter compartment between transporting soiled dishes and food. No information about specific residents or their medical conditions was provided in the report.
Failure to Adhere to Enhanced Barrier Precautions and Proper Disinfection of Shower Facilities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and improper cleaning and disinfection of shower facilities. For two residents on EBP due to wounds and pressure ulcers, staff did not consistently wear the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities. Observations revealed that staff entered rooms and provided care, including transferring residents and changing briefs, without donning the appropriate PPE, despite clear signage and care plans indicating the necessity of EBP for these residents. Interviews with staff confirmed a lack of understanding or adherence to the EBP requirements, with some staff incorrectly believing that gowns were only needed for certain activities or that the signage applied to other residents. Additionally, the facility did not ensure that shower facilities and equipment were properly cleaned and disinfected between residents. In one instance, a shower chair was found with dried brown matter, and a staff member acknowledged that it had not been cleaned after previous use. Another observation documented a strong odor of feces and visible fecal matter on the shower floor after a resident's shower. The staff member removed the feces but did not use any cleaning or disinfectant products before bringing another resident into the same shower stall. The staff member admitted to not using disinfectant after every resident, contrary to facility policy and infection control standards. The facility's own policies required the use of PPE during high-contact care for residents on EBP and mandated cleaning and disinfection of reusable equipment and shower areas between residents. Despite these policies, direct observations and staff interviews demonstrated repeated failures to follow established infection prevention protocols, resulting in deficiencies in both resident care and environmental sanitation.
Failure to Address and Care Plan for Repeated Refusals of Hygiene and Nail Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's repeated refusals of hygiene and nail care. Record reviews showed that the resident, who had diagnoses including schizoaffective disorder, unspecified dementia, anxiety disorder, and major depressive disorder, consistently refused hygiene care daily over a two-month period and refused nail care on multiple occasions. Hospice aide visit notes also documented refusals of nail care, with notifications made to nursing staff. Despite these ongoing refusals, the resident's care plan did not include any identification of the refusal of care or interventions to address it. Interviews with facility staff, including LPNs and the nurse responsible for MDS and care plan updates, confirmed that the refusals were known and occurred frequently, yet were not reflected in the care plan. The staff acknowledged that the care plan should have included these issues and interventions but did not.
Some of the Latest Corrective Actions taken by Facilities in Louisiana
- Established policy requiring at least one CNA to remain on each hall at all times through targeted staff in-service sessions (J - F0689 - LA)
- Trained CNAs and nurses on two-hour rounding and mandatory resident head-counts at every shift change to enhance supervision consistency (J - F0689 - LA)
- Instructed all staff on new exit-door code confidentiality and the requirement that residents be supervised whenever outside to deter elopement risks (J - F0689 - LA)
- Implemented a multi-layer identification system for residents needing hourly visualization using computer tasks, MAR orders, bed signage, care-plan notes, and a posted list (J - F0689 - LA)
- Implemented alternating hourly rounding schedule with CNAs rounding on odd hours and nurses on even hours, documented and reviewed by DON/ADON (J - F0689 - LA)
- Initiated random camera-footage audits by DON/ADON to verify CNA presence on halls and limit excessive staff breaks (J - F0689 - LA)
- Started random in-person or video verification of rounding compliance each week by DON/ADON with immediate remediation of non-compliance (J - F0689 - LA)
- Developed an ongoing random elopement-knowledge questionnaire for CNAs and nurses to confirm understanding of protocols (J - F0689 - LA)
Failure to Supervise Elopement Risk Resident Leads to Immediate Jeopardy
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and accident hazard prevention for a resident at risk for elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and schizophrenia, was court committed to the facility and assessed as a wander/elopement risk. The care plan required visual checks of the resident's location every hour, diversional activities, and redirection as needed. Despite these interventions, the resident was able to exit the facility unsupervised by entering the code to a locked exit door, which he had obtained, and left the premises during the night. The last staff observation of the resident occurred at 1:55 a.m., but the resident was not visually checked every hour as required by the care plan. Staff responsible for the resident's care admitted to not performing the required hourly monitoring due to being occupied with other residents. The resident was discovered missing only after being found by a maintenance supervisor at a gas station approximately five miles from the facility, having traversed a four-lane highway. The resident was returned to the facility by the local sheriff's office without injury. Interviews with facility leadership and staff revealed they were unaware that the resident had access to the exit door code and that the required hourly visual checks were not being performed. The Director of Nursing and Assistant Director of Nursing confirmed that staff were not following the care plan interventions for monitoring the resident, and that there was a lack of awareness regarding the resident's ability to access secured exits. The failure to provide adequate supervision and to follow established protocols for a resident at risk for elopement resulted in an Immediate Jeopardy situation.
Removal Plan
- The ADON did a check for all admitted residents to establish a complete baseline.
- Resident #1 was placed 1:1 with staff upon return to the facility until departure.
- The ADON counseled all CNAs and Nurses for their lack of supervision of residents and excessive break time and provided all CNAs and Nurses with a disciplinary write up.
- The ADON and Maintenance Supervisor assessed all exit doors of the building to ensure they were locked and the codes were functioning properly. Codes to the exit doors were updated.
- The DON inserviced all CNAs and Nurses. At least one CNA must remain on the hall at all times for proper supervision of residents.
- The DON inserviced all CNAs and Nurses on importance of attentive supervision (every 2 hours rounding during assigned shift), as well as required rounding at each shift change to ensure all residents are safe and accounted for. All staff was inserviced prior to returning to work.
- The DON inserviced all staff that door code exits were changed and the new codes must not be given out to residents or visitors. Inservice also stated that any resident who wished to go outside must be supervised by staff. All staff was inserviced prior to returning to work.
- To verify understanding of all inservices an elopement questionnaire was developed and administered by DON and ADON and was completed by all nurses and CNAs. All staff inserviced prior to returning to work.
- All residents were reassessed by MDS and Clinical Care Coordinator (CCC) nurse for baseline to determine any other risk for elopement.
- All residents who require every 1 hour visualization are identified by a task on the computer, ordered on Medication Administration Record (MAR), signage above assigned bed, closet care plan and a list posted by the time clock.
- A construction company was notified by the Administrator that the fence needed improvements at the facility.
- A construction company repaired the fence.
- The DON or ADON will monitor camera footage at random to ensure that CNAs and nurses are not taking excessive break times and that at least one CNA remains on each hall at all times. This monitor will be completed at random and any noncompliance will be addressed.
- The CNAs and LPNs will rotate every 2 hour rounds through the facility so that all residents have a visual check every 1 hour by staff. CNAs will round on odd hours and nurses will round on even hours. These forms will be turned into the DON and ADON to ensure that this implementation is being followed. Rounding will be completed every 1 hour on all residents and will continue on all residents who have a every 1 hour monitor order but may continue until compliance is met.
- Residents identified for every 1 hour monitoring are identified by signage above their bed, listed on closet care plan, order in Kiosk for CNAs, order in the computer for nurses, as well as a list by the time clock. Any noncompliance will be addressed.
- The DON and ADON will visualize rounds with CNAs and LPNs at random times throughout the week to ensure compliance either by in person or reviewing camera footage. This monitor will be completed at random but may continue weekly until compliance is reached. Any noncompliance will be addressed.
- An Elopement Questionnaire will be completed with 2 CNAs and 1 nurse at random by the DON or ADON. Any noncompliance will be addressed.
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