Citations in Louisiana
Statistics, citations 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
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
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Compliance trends in Louisiana
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Louisiana
- Implemented a policy requiring all nurses (including new hires) to be trained on checking residents’ code status in the EMAR and proper CPR procedures prior to working on the floor (L - F0678 - LA)
- Removed the code status binder and red dot stickers and required code status be verified in the EMAR (L - F0678 - LA)
- Established DON monitoring to verify required training was completed before nurses were scheduled to the floor (including weekly audits of training documentation and withholding scheduling if training was incomplete) (L - F0678 - LA)
- Updated the resident-death review policy/procedure and implemented a Death Review form with required DON/designee review (including unexpected/high-risk deaths) and QAPI review/monitoring of Death Review forms and follow-through on discrepancies (L - F0835 - LA)
Failure to Ensure CPR per Code Status and Wound Care Coverage in Absence of Treatment Nurse
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical well-being, specifically in relation to CPR and code status verification. One resident with a physician’s order for full code status was found unresponsive, pulseless, and not breathing. Licensed nursing staff did not accurately determine this resident’s code status and failed to initiate and continuously provide CPR in accordance with the physician’s full code order until EMS arrived. When the hospice nurse arrived, no life-saving measures were in progress, and the resident was later pronounced deceased. The DON stated she had not identified this incident as deficient practice at the time it occurred and did not realize the magnitude of the problem until it was brought to her attention during the survey. The DON also acknowledged that the facility did not provide additional education to nursing staff on verifying code status and continuing CPR until EMS assumed responsibility. The facility’s administration, including the Administrator and DON, did not have an adequate system in place to identify this deficient practice, determine its root cause, or ensure that nursing staff were trained and competent in verifying residents’ code status and implementing CPR according to orders. The Administrator indicated that when it was discovered that the LPN had not properly determined the resident’s code status and had not continued CPR until EMS arrival, administrative staff should have reviewed the incident to determine the root cause and re-educated nursing staff on the CPR policy and procedure. However, this did not occur prior to the surveyors’ identification of the issue. As a result, the surveyors determined that an Immediate Jeopardy situation existed related to the failure to ensure CPR was initiated and continued for a resident with full code status. A second deficiency involved the facility’s failure to have an adequate system to ensure that licensed nursing staff were made aware of their responsibilities for wound care in the absence of a Treatment Nurse. Multiple residents with pressure ulcers did not receive wound care as ordered by their physicians on days when no Treatment Nurse was assigned. The Treatment Nurse stated that weekend nurses should perform wound care when a Treatment Nurse is not present. Several LPNs reported they did not provide ordered wound care to residents with Stage III and Stage IV pressure ulcers because they were not aware they were responsible for completing wound care on their assigned residents. The DON indicated that on specific dates without a Treatment Nurse, it was the RN Supervisor’s responsibility to remind floor nurses to complete wound care, and a communication sheet instructed the RN Supervisor to remind nurses to perform wound care and sign the Treatment Administration Record. The RN Supervisor stated it was an understood responsibility that floor nurses were responsible for wound care in the absence of a Treatment Nurse, but the interviewed LPNs’ statements showed they had not been effectively informed of this responsibility, resulting in missed wound treatments as ordered. Overall, the facility’s administrative systems did not ensure that critical clinical responsibilities—verifying and acting on residents’ code status with appropriate CPR, and providing ordered wound care in the absence of a Treatment Nurse—were clearly assigned, communicated, and carried out by nursing staff. The DON’s and Administrator’s own interviews confirmed that they had not identified the CPR incident as deficient practice at the time, had not conducted a root cause review, and had not re-educated staff on CPR procedures, and that the process for ensuring wound care coverage on days without a Treatment Nurse relied on informal understandings rather than a consistently implemented system, leading to missed treatments for residents with pressure ulcers.
Removal Plan
- In-service nurses on checking a resident's Code Status in the EMAR and proper procedures for CPR.
- Review all active residents' EMAR to ensure Code Status is posted.
- Identify residents with DNR status.
- In-service all nurses on each shift on checking Code Status in the EMAR and proper procedures for CPR.
- Update the policy and procedure for Review of Resident Deaths.
- Implement a Death Review form for the DON and/or Quality Nurse to complete and immediately initiate changes as needed.
- Require all resident deaths be reviewed by the DON/designee.
- Require unexpected/high-risk deaths be reviewed by the DON/designee.
- Require cases be presented to QAPI at the next scheduled meeting.
- Consult on the death review policy/procedure, how to complete the Death Review form, actions for discrepancies, training nurses to look up code status in the EMAR, and proper CPR procedure.
- QAPI Team to verify the DON is reviewing completed Death Review forms and following through on discrepancies.
- QAPI to monitor Death Review forms.
- QAPI to review all Death Review forms.
Failure to Provide CPR According to Full Code Status and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, in accordance with a resident’s documented full code status and physician orders. The facility’s CPR policy required staff to provide basic life support prior to the arrival of emergency personnel, consistent with the resident’s physician orders and advance directives. The American Heart Association Basic Life Support Algorithm referenced in the report emphasized that high-quality CPR is the most critical part of basic life support and should continue until advanced medical providers arrive or the patient shows signs of life. For this resident, multiple documents, including a Louisiana Physician Orders for Scope of Treatment form, monthly physician orders, hospice certification and plan of care, and the comprehensive care plan, all indicated a full code status, requiring CPR if the resident was unresponsive, pulseless, and not breathing. On the day of the incident, the resident, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, stage 5 chronic kidney disease, and chronic obstructive pulmonary disease, was found unresponsive and not breathing. Surveillance footage showed that a CNA exited the resident’s room and quickly summoned the CNA supervisor, who then returned to the room and called for additional staff. Two LPNs entered the room shortly thereafter, but video review from the time the incident began until well after showed that no cardiopulmonary emergency equipment, such as a backboard, Ambu bag, or crash cart, was brought into the room. Documentation in a health status note by one of the LPNs stated that she was summoned to the room, found the resident unresponsive and not breathing, and that she attempted CPR but was unsuccessful, with the time of death later documented as pronounced by the hospice nurse. Interviews and video review, however, did not corroborate that CPR was initiated or continued as required. One LPN reported that when she assessed the resident, he had no pulse, was still warm, and showed no signs of prolonged death, but she did not discuss or verify the resident’s code status and assumed the resident was DNR because he was on hospice. She stated she was not aware the resident was full code and had not observed anyone performing CPR. The DON reported that the other LPN had initially believed the resident was DNR and admitted she had not yet implemented CPR; the DON then instructed her to return to the room and start CPR. The hospice nurse stated she was notified that the resident had expired and, upon arrival, found the resident in bed with a sheet over his head and no life-saving measures in progress. She was told that CPR had been started and stopped, but she did not instruct staff to stop CPR and expected it to continue until EMS or a physician directed otherwise. The facility was unable to provide evidence that any licensed nursing staff immediately verified the resident’s code status or ensured continuous CPR from the time the resident was found without a pulse and not breathing until the official time of death, resulting in an Immediate Jeopardy determination.
Removal Plan
- S5LPN was in-serviced on checking Code Status in the Electronic Medication Administration Record (EMAR) and proper procedures for CPR.
- All active residents' EMARs were reviewed to ensure code status was posted.
- All nurses for each shift were in-serviced for checking code status in the EMAR and proper procedures for CPR.
- Implemented a policy to train all nurses on checking code status in the EMAR and proper procedures for CPR prior to working on the floor.
- All new hire nurses will be trained on checking code status and proper procedures for CPR prior to working on the floor.
- Removed the code status binder and red dot stickers; they are no longer in use.
- Required that a resident's code status must be checked in the EMAR.
- The DON will monitor weekly to ensure proper training is provided to all nurses and completed prior to working on the floor.
- The DON will audit training documents prior to scheduling nurses to the floor on a weekly basis and before all new hires.
- The DON will not schedule any nurse who has not completed the required training.
Unverified Individual Assigned to Provide Direct Resident Care Without Screening or Orientation
Penalty
Summary
The deficiency involves the facility’s failure to administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift. Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room. Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered. The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.
Removal Plan
- Removed the individual (S12) from the facility and ensured only verified nursing staff were permitted to provide resident care.
- Conducted an immediate search of the facility to locate S12 and confirmed she was no longer present in the building.
- Verified with the staffing agency that S12 was not employed by the agency and confirmed through the facility staffing system that she was not an active employee.
- Ensured S12 was not permitted to provide resident care and confirmed she was no longer present in the building.
- Contacted the Police Department to document the incident and obtain identifying information related to S12.
- Implemented monitoring of the front entrance to ensure all individuals entering are identified, verified, and logged in before entering.
- Interviewed residents assigned to the unit where S12 was listed on the assignment sheet to determine whether she provided care or performed CNA duties.
- Interviewed all residents with a BIMS score of 8 or greater regarding concerns related to care provided by unknown staff.
- Completed head-to-toe assessments for residents with a BIMS score less than 8 to evaluate for signs of injury, neglect, abuse, or improper care.
- Implemented a trained facility staff member as a front desk monitor to verify all individuals entering the facility.
- Required all staff and visitors entering the building to sign in and out at the front desk.
- Continuously monitored the front desk to ensure the entry process is followed and unknown individuals are not allowed entry.
- Changed keypad door codes throughout the facility, deleted previously stored codes, and input new codes to prevent unauthorized access.
- Educated all staff in all departments on verification of agency staff to be completed by the scheduler and/or Payroll Benefits Coordinator and maintained on file prior to placement on the daily schedule; on weekends/holidays verification to be performed by the DON.
- Verified abuse training requirements for agency staff by obtaining documentation from the agency and providing facility abuse training at the beginning of the agency staff member’s first scheduled shift.
- Educated staff on the responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring resident safety.
- Educated staff on facility entry procedures and sign-in requirements.
- Educated staff on abuse prevention and resident safety.
- Completed education for staff not present during initial sessions prior to their next scheduled shift.
- Provided education/training for leadership/administrative staff by the Chief Nursing Officer with the Regional Director of Clinical.
- Implemented regional/corporate onsite monitoring of administrative staff compliance with agency staff verification and abuse training, and compliance with sign-in/out and continuous front desk monitoring.
- Restricted resident care assignments to only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment.
- Administrator and DON to review the entry sign-in log daily and ongoing to ensure all staff entering are verified.
- Administrator, DON, ADON, and SDC to conduct random audits of staffing assignments and ongoing to confirm only verified employees/agency staff provide resident care.
- Required verification of agency staff credentials and agency confirmation to be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator.
Failure to Secure Wheelchair-Dependent Resident and Provide Supervision During Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of the transportation van’s restraining seatbelt for a wheelchair-dependent resident during transport. The facility had a written Transportation Policy and Passenger Assistive Techniques procedure requiring that residents who use wheelchairs be safely secured with passenger restraints and that seat belts be used for all passengers. The CNA responsible for transport had completed the Transportation Training Checklist and acknowledged the transportation policy and passenger assistive procedures, which included guidance on safe wheelchair transportation, use of restraints, and what to do if someone falls. The resident involved was admitted with multiple significant diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, was dependent on a wheelchair for mobility, and required staff assistance with transfers using a lift. Despite this dependence on staff for safe mobility and transfers, the resident was transported in the facility van without the restraining lap belt being applied. During the return trip from a medical appointment, the resident reported to the CNA driver that she felt she was sliding down in her wheelchair. The CNA did not stop the van to reposition or secure the resident with the restraining seatbelt and continued driving until reaching her own personal residence. The CNA then left the resident unattended in the van while she went inside her residence. While unsupervised and not secured by a seatbelt, the resident slid out of the wheelchair onto the floor of the van. When the CNA returned, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. Instead, the CNA drove the resident back to the facility while the resident remained sitting on the floor of the van. Upon arrival, staff, including an LPN, observed the resident on the van floor and assisted with assessment and lifting the resident from the floor. The incident was determined by surveyors to constitute an Immediate Jeopardy situation on the date of occurrence.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers to communicate policy changes and perform competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee: checks upon arrival and departure 3 times per week to ensure residents are safely anchored in the van and properly seated; quiz transport drivers at each departure/arrival on who to call in the event of a fall; counsel on notifying nursing immediately in the event of a fall.
- Monitor compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Resident Neglect During Unsafe Wheelchair Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transportation in the facility van. A CNA responsible for transport did not follow the facility’s transportation safety policies and procedures, including the requirement to properly secure residents with restraining seatbelts. The resident involved had multiple medical diagnoses, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic heart failure, type 2 diabetes with autonomic neuropathy, chronic pain due to trauma, cervical spinal stenosis, and COPD. The resident was cognitively intact with a BIMS score of 15 and was dependent on a wheelchair for mobility and staff assistance for transfers using a lift. During a return trip from a physician appointment, the CNA failed to attach the van’s restraining lap belt across the resident’s lap. While en route, the resident told the CNA that she felt like she was sliding down in her wheelchair. Despite this verbal report, the CNA did not stop the van to reposition the resident or correct the lack of restraint. Instead, the CNA continued driving until reaching her personal residence. The CNA then went inside her residence, leaving the resident unattended in the van and still not properly secured or repositioned. While the CNA was inside her personal residence, the resident slid out of her wheelchair onto the floor of the transportation van. When the CNA returned to the van, she found the resident on the floor but did not call the facility for assistance and did not transfer the resident back into the wheelchair. The CNA then drove approximately 15.3 miles back to the facility with the resident remaining on the floor of the van. Upon arrival, the CNA did not inform facility staff when the fall had occurred or how long the resident had been on the floor. The resident was later assessed with no injuries, and the facility’s investigation substantiated neglect based on these events and the CNA’s failure to follow established policies on abuse, neglect, fall management, and transportation safety. The facility’s policies in place at the time defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The transportation policy required adequate training of personnel transporting residents, including safe wheelchair transportation, proper use of restraints, and procedures for what to do if someone falls. The CNA had completed annual abuse and neglect training and had acknowledged the transportation training checklist and passenger assistive techniques, which included always using seat belts and ensuring passenger restraints fit securely. Despite this training and policy framework, the CNA did not secure the resident with the lap belt, did not respond appropriately when the resident reported sliding, left the resident unattended in the van, failed to seek assistance after the fall, and transported the resident back to the facility while she remained on the floor of the van. These actions and inactions led to the substantiated neglect and the Immediate Jeopardy determination.
Removal Plan
- Immediately assessed Resident #26 upon return to the facility.
- Terminated the employment of S4CNA.
- Updated the facility's transportation policy to state to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency.
- Completed an in-service with transportation drivers regarding policy changes and performed competency checks on loading and unloading residents in wheelchairs; counseled drivers on never leaving residents unsupervised and on notifying nursing immediately in the event of a fall.
- Implemented mandatory monitoring by the DON or designee 3 times per week, including checks on arrival/departure to ensure residents are safely anchored and properly seated, quizzing drivers on who to call in the event of a fall, and speaking with residents about their trip.
- Monitor transportation compliance weekly at staff meetings and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.
Neglect During Resident Van Transport and Failure to Report Incident
Penalty
Summary
The deficiency involves the neglect of a wheelchair‑dependent resident during transport by a facility van. The resident had ataxia, required a wheelchair for mobility, and was care planned to need staff assistance for all ADLs due to an unsteady ataxic gait. On the date of the incident, the transport driver was responsible for taking the resident to a medical appointment using the facility’s transport van. The driver had previously received training on how to safely transport and secure wheelchair‑bound residents in the van. The driver reported that when loading the resident, he believed he did not have the appropriate wheelchair seat belt or safety straps available in the van. Instead of reporting this to administration or refusing to transport without proper equipment, he placed the resident in his wheelchair in the back of the van between two seats and attempted to secure the resident by using a regular van seat belt. He attached the seat belt from a van seat to the side of the wheelchair, wrapped it around the resident, and fastened it to the seat belt buckle, despite knowing this was not the correct method and that it did not properly secure or lock the resident in place. The facility’s vehicle safety checklist completed earlier in the month documented that all doors, seat belts, and wheelchair straps were present and working properly, and subsequent inspection after the incident confirmed that wheelchair seat belts and safety straps were in the van and in good repair. As the driver exited the facility parking lot with the resident in the wheelchair, the van hit a pothole, causing the back door to open, the ramp to deploy, and the resident to roll backwards out of the van onto the gravel driveway. Video surveillance reviewed by the administrator and DON showed the van exiting, hitting the pothole, the back door opening, the ramp coming down, and the resident rolling down the ramp onto the gravel. The driver stopped, assisted the resident back into the van, and placed the resident into a regular van seat. He then drove away from the facility without notifying the administrator, DON, or other facility staff of the incident, despite facility policy requiring immediate reporting of all incidents and accidents during transport. The facility only became aware of the event when a passerby who witnessed the fall came into the building and reported what they had seen. The driver later acknowledged that he knew he should have reported the incident at the time it occurred.
Removal Plan
- S2DON drove S3TD back to the facility and S8TD drove Resident #1 back to the facility using a regular van seat and the van seatbelt; S3TD was suspended pending investigation.
- S9NP assessed Resident #1 and noted no injuries and no complaints of pain.
- Van keys were locked in S1ADM’s office and the van was not used again.
- Corporate Maintenance Coordinator, Maintenance Supervisor, and S1ADM inspected the van; found missing screws on the back door latch; confirmed wheelchair straps and regular seatbelts were available and working; confirmed wheelchair ramp and latches were in good working order.
- The van was taken out of service and removed from site.
- S1ADM in-serviced transportation staff on proper restraint/securement for residents transported via wheelchair (demonstration) and on notifying the Administrator and/or DON immediately of any issues/incidents and reviewing van forms/binder; clarified that residents who can safely transfer to a van seat may ride in a traditional seat.
- S3TD was terminated.
- The Administrator completed a ride-along with S8TD and S7TD and completed the Driver In-service Checklist and the Transportation Policy Acknowledgement Form.
- A 3rd party consultant provided training on wheelchair securement and lift operations and issued certificates of completion (S7TD, S8TD, S1ADM, S21ESS).
- Administrator ordered additional transport safety items discussed during the 3rd party training: a seatbelt lock and Q-straint loops; items were placed into the van.
- Transportation monitoring was initiated weekly for 6 weeks via Administrator/designee ride-alongs to ensure resident safety, proper securement, and safe driving.
- Facility borrowed a van from a sister facility to continue resident transports and completed Driver In-service Checklists.
- Facility rented vans so bariatric residents could be safely transported and completed Driver In-service Checklists.
- Facility scheduled ambulance transfers as needed.
- Administrator/designee planned ongoing ride-alongs/training with each approved van driver approximately every 6 months.
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