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 Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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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