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 severely impaired cognition and a history of traumatic subdural hemorrhage had a physician order for DNR with selective treatment, but the care plan continued to indicate Full Code status. An LPN confirmed the care plan was not updated to reflect the current DNR order, resulting in inconsistency between the care plan and the resident's documented treatment preferences.
Two residents were not treated with dignity during meal and personal care routines. One resident, dependent on staff for eating, was left unserved at the dining table while others finished their meals, as her tray was intentionally prepared last due to her need for feeding assistance. Another resident, with severe cognitive impairment and incontinence, was repeatedly observed in a soiled brief and was offered breakfast without prior incontinence care, which staff acknowledged was inappropriate and could have affected the resident's willingness to eat.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific staff actions or resident involvement are provided.
A resident with severe dementia and a DNR order was found to have an outdated care plan that incorrectly listed her as Full Code. The discrepancy was confirmed by an LPN, who acknowledged that the care plan had not been updated after the resident's code status changed to DNR.
A resident's nasal cannula used for oxygen therapy was repeatedly found lying on the floor without being stored in a bag, contrary to facility policy. An LPN confirmed the equipment was not properly labeled or stored between uses, despite the resident's recent use of oxygen.
A resident with severe cognitive impairment, dysphagia, and a history of choking or coughing during meals had physician's orders for oral suctioning, but the care plan did not include suctioning as an intervention. This omission was confirmed by the DON during interview.
A medication error rate above 5% was identified when an LPN crushed and administered DR and ER medications, including Pantoprazole, Tolterodine, and Potassium Chloride, inappropriately to a resident. The contract pharmacist confirmed these medications should not have been altered, and no supporting documentation was provided.
Staff failed to follow infection prevention and control protocols, including not using required PPE for a resident with a gastrostomy tube, improper hand hygiene and glove use during meal service, and inadequate infection control during wound care. These actions resulted in multiple lapses in standard precautions and EBP requirements.
Surveyors found that a medication cart contained five unidentified, loose tablets and that two inhalers in use were not labeled with their open dates. An LPN confirmed the presence of the loose pills and the lack of labeling on the inhalers, and the facility's contract pharmacist stated that these inhalers require open-date labeling for proper disposal timelines.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, and neglect by any individual.
Failure to Update Care Plan to Reflect DNR Status
Penalty
Summary
The facility failed to update the care plan for a resident to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) as ordered by the physician. The resident, who had a history of traumatic subdural hemorrhage and was assessed as having severely impaired cognition, was admitted with a care plan indicating Full Code status. However, a physician order for DNR with selective treatment was initiated, and this change was not reflected in the resident's care plan. Staff interview confirmed that the care plan had not been revised to match the current physician order, resulting in a discrepancy between the resident's documented treatment preferences and the care plan.
Failure to Maintain Resident Dignity During Meal and Incontinence Care
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, and that their care promoted or enhanced their quality of life. One resident, who required substantial assistance with eating and was unable to communicate effectively, was observed sitting at a dining table during lunch while other residents were served, ate, and left the area. This resident was not served her meal along with the others, and staff interviews confirmed that her tray was intentionally prepared last because she required feeding assistance. The LPN on duty was unaware that the resident had not been served, despite all other residents at the table having completed their meals. Another resident, with severe cognitive impairment and a history of incontinence, was observed multiple times in bed with a soiled brief and a strong odor of feces in the room. Despite these observations, staff attempted to feed the resident breakfast without providing incontinence care beforehand. The LPN confirmed that the resident should have received incontinence care prior to being served breakfast and acknowledged that the lack of care could have contributed to the resident's refusal to eat. The DON also confirmed that incontinence care should have been provided before attempting to feed the resident.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
A deficiency occurred when a resident's code status was not accurately reflected in the care plan. The resident, a 93-year-old female with diagnoses including traumatic subdural hemorrhage, severe unspecified dementia, and cognitive communication deficit, was admitted and later re-entered the facility. Her medical record indicated a DNR (Do Not Resuscitate) order with selective treatment, but the care plan continued to list her as having a Full Code status. This discrepancy was identified during a review of the resident's electronic chart and care plan documentation. An interview with an LPN and review of the care plan confirmed that the resident's code status had recently changed to DNR, but the care plan had not been updated to reflect this change. The care plan still instructed staff to treat the resident as Full Code, which was inconsistent with the current physician's order and the resident's wishes. This failure to update the care plan compromised the resident's right to have her treatment preferences honored.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident who required oxygen therapy. According to the facility's policy, oxygen equipment should be stored in a covered device, such as a plastic bag or kangaroo pouch, between uses to ensure safe administration and infection prevention. However, observations on two consecutive days revealed that the resident's nasal cannula was found lying on the floor without a bag. The resident confirmed recent use of the oxygen equipment, and an LPN acknowledged that the tubing was not properly stored or labeled as required by facility policy.
Failure to Care Plan for Suctioning in Resident with Dysphagia and Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with significant medical needs. The resident was admitted with diagnoses including dysphagia, cerebral infarction, and unspecified convulsions, and had a BIMS score of 3, indicating severe cognitive impairment. The resident experienced episodes of coughing or choking during meals or when taking medications. Physician's orders dated 08/08/2025 indicated that oral suctioning may be performed for this resident. However, review of the resident's care plan showed that suctioning was not included as an intervention. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have been care planned for suctioning but was not.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by direct observation of medication administration. During 29 observed medication administration opportunities, an LPN was seen crushing and administering Pantoprazole DR 40mg tablet and Potassium Chloride ER 10meQ tablet, as well as opening a Tolterodine ER 4mg capsule and providing its contents orally to a resident. The LPN confirmed these actions during an interview. The facility's contract pharmacist verified that these extended-release (ER) and delayed-release (DR) medications should not have been crushed or opened, and stated that no documentation existed to support altering these medications in this manner. This practice had the potential to affect all 145 residents receiving medications in the facility.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff adherence to established protocols. In one instance, a resident with a gastrostomy tube, who was identified as requiring Enhanced Barrier Precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition, did not receive care in accordance with EBP guidelines. The assigned CNA provided a bed bath, oral care, brief change, and linen change to the resident while wearing only gloves, omitting the required gown. The CNA admitted to not using the correct PPE for all EBP-designated residents on her hall, citing lack of PPE availability at the point of care and uncertainty about where to obtain supplies, despite facility policy and signage indicating the need for both gown and gloves during direct care activities. During meal service on another hall, a CNA was observed repeatedly failing to follow proper hand hygiene and gloving procedures. The CNA served and prepared meals while wearing the same pair of gloves, touching various surfaces, utensils, and food items, including bread rolls, without changing gloves or performing hand hygiene between tasks. The CNA also used gloves obtained from a co-worker's pocket and handled clean utensils with unwashed hands after glove removal. The CNA confirmed these lapses in practice, acknowledging that she did not follow the required procedures for hand hygiene and glove use during meal service for multiple residents. Additionally, improper infection control practices were observed during wound care for a resident with pressure ulcers and blisters. The treatment nurse used gloved hands to move the bedside table and then proceeded to apply wound dressings without changing gloves or performing hand hygiene. The nurse also touched her gown and clothing before continuing wound care on a different site, again without changing gloves or sanitizing hands. The nurse confirmed these actions, recognizing that they did not align with proper infection control protocols as outlined in facility policy.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional principles. During an inspection of medication carts, one cart was found to contain five unidentified and loose tablets in two separate drawers. Additionally, two inhalers—Albuterol and Trelegy Ellipta—were found opened and in use without being labeled with the date they were opened. The LPN present confirmed the presence of the loose, unidentified tablets and acknowledged that the inhalers had been opened and used without proper labeling. The facility's contract pharmacist verified that both types of inhalers require labeling with the date opened to ensure timely disposal according to manufacturer guidelines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Some of the Latest Corrective Actions taken by Facilities in Louisiana
- Updated the abuse-and-neglect policy to define any staff-resident sexual relationship as an abuse of power (J - F0600 - LA)
- Delivered focused in-service training on resident-protection responsibilities and the revised abuse policy, accompanied by baseline competency interviews (J - F0835 - LA) (J - F0600 - LA)
- Implemented random staff interviews under QAPI to monitor ongoing awareness of immediate-protection procedures, with findings reviewed at QAPI meetings (J - F0835 - LA)
- Established continuing post-event monitoring of residents and staff for indications of inappropriate sexual behavior until compliance is assured (J - F0600 - LA)
Immediate Jeopardy Due to Unsanitary Kitchen and Unsafe Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, resulting in conditions that could lead to cross-contamination and foodborne illness for the 40 residents who consumed meals prepared in the kitchen. During the initial kitchen tour, surveyors observed significant accumulations of food debris, grease, and residue on equipment such as the ice machine, ovens, meat slicer, and food preparation surfaces. The dish and cookware storage areas were also found to be unsanitary, with dried substances and food debris present on shelves and racks intended for clean items. Floors throughout the kitchen, walk-in cooler, and dry storage room were dirty, with sticky residues, food debris, and spoiled produce observed. Additionally, the kitchen wall near the walk-in cooler was splattered with dried food debris, and there was no documentation of temperature monitoring for a refrigerator containing food items. Food storage practices were also deficient, with numerous refrigerated items found to be unlabeled, undated, or expired, including salad dressings, juices, sandwiches, and various containers of food. Some food items, such as cucumbers and hot dog buns, were visibly spoiled or moldy. Staff interviews confirmed a lack of knowledge regarding the safety and storage duration of these items, and staff were observed preparing to serve unlabeled and undated food to residents. The facility's cleaning schedule was not being followed, as no cleaning was observed between meal services, and staff could not provide evidence of when scheduled cleaning tasks had last been completed. Interviews with the dietary manager, dietary aide, administrator, and infection preventionist confirmed awareness of the unsanitary conditions and acknowledged failures in oversight and adherence to food safety policies. The dietary manager admitted to not monitoring the kitchen's cleanliness, and the infection preventionist recognized that the conditions could put residents at risk for foodborne illness. The registered dietician and other staff also confirmed that the kitchen was not being maintained in a clean and sanitary manner, and that food storage practices were not in compliance with professional standards.
Removal Plan
- Interviewed dietary manager and dietary staff to assess knowledge of regulations and sanitation processes.
- Reviewed dietary policy and procedures regarding food storage, sanitation, cleaning schedules, and temperature checks.
- In-serviced dietary manager and staff on facility's policy and procedures with pre/posttest to ensure understanding.
- Ongoing training for all remaining dietary staff prior to their work shift.
- Administrator to set up education in-service with the registered dietician.
- Registered dietician to round and audit kitchen area.
- Administrator to round in the kitchen until compliance is met.
- Prepared and provided supper for residents from the facility's sister facility after kitchen closure.
- Arranged for all meals to be prepared and provided by the sister facility until the kitchen reopens.
- All meals to be served from the secondary steam table located outside the main kitchen area.
- Initiated immediate sanitation process in the kitchen with assistance from corporate staff.
- Discarded molded bread and vegetables.
- Discarded all unlabeled and expired refrigerated foods.
- Checked and ensured all other items were labeled and dated.
- Provided verbal in-service to dietary staff on kitchen hood inspection and cleaning, maintaining a sanitary tray line, food safety requirements, sanitation inspection, cleaning schedules, and temperature checks.
- Utilized pre/posttest for continued education to ensure understanding with dietary staff.
- Implemented Dietary Sanitation Orientation checklist for all current and new dietary staff.
- Registered dietician to make sanitation rounds at the facility until compliance is met.
- Administrator to round in the kitchen.
- Administrator to monitor: sanitary storage and safety, refrigerator and freezer cleanliness, work area cleanliness, major equipment and utensils cleanliness, storage area cleanliness, food coverage, labeling and dating, separation of food and non-food supplies, trash container cleanliness and coverage, food storage off the floor, proper scoop storage, posted cleaning schedule, clean utility area for mop storage, clean dishwashing area, dishes without stains and residue, proper wash/rinse temperatures, clean pots and pans, staff personal hygiene, use of hair restraints, proper storage of personal items, and proper hand washing techniques.
- Disciplinary actions to be taken if further non-compliance is noted.
- Plan to be implemented into the facility QAPI process and reviewed with IDT at meetings.
- Implemented a detailed cleaning schedule for specific kitchen areas and equipment by day of the week.
- Implemented a master cleaning schedule with frequency for extractor hood, filters, grease traps, oven, flat top, grill, cookers/burners, oil fryer, equipment legs/supports, gas pipes/taps, warmer, cleaning equipment, refuse areas, floors, doors, and walls.
Failure to Recognize and Respond to Exit-Seeking Behaviors Resulting in Resident Elopement
Penalty
Summary
Facility staff failed to recognize and appropriately respond to a resident exhibiting exit-seeking behaviors, resulting in the resident eloping from the facility. The resident, who had a diagnosis of Alzheimer's disease and dementia with moderate cognitive impairment, repeatedly asked staff for the code to the facility's door alarm and expressed a desire to go home. Despite these clear indications of exit-seeking, staff did not interpret these behaviors as a risk for elopement and did not take preventive action. On the day of the incident, the resident approached multiple staff members requesting to be let out and for the door code. Staff directed the resident to speak with the nurse but did not monitor his movements or alert other staff to his intentions. When the door alarm sounded as the resident exited, staff were unable to identify the source of the alarm or its significance. One staff member checked the door, did not see anyone outside, and disarmed the alarm without confirming the resident's whereabouts. The resident was able to leave the facility undetected and walked approximately 0.2 miles to his home, where he was later retrieved by facility staff. Interviews and record reviews revealed that the staff involved were unfamiliar with the facility's alarm system and did not know how to respond to or locate the source of an alarm. The facility's elopement policy did not provide clear guidance on alarm response or recognizing exit-seeking behaviors. Additionally, the staff members involved had only recently started working at the facility and had not received adequate training on these procedures prior to the incident.
Removal Plan
- The facility initiated in-service with staff regarding door alarms within the facility and the Elopement Policy.
- Staff were educated on how to respond to an activated door alarm.
- An additional in-service on the Door Guardian, Wander Guard Policy to all staff on duty was conducted.
- Pictures of the alarming modules located at the nurse's stations were presented to staff for visual recognition.
- Education continued to all staff as they came for their assigned shifts.
- The facility continued to educate to all on coming staff members on the policies and procedures for dealing with elopements, residents with elopement risk, alarming doors and how to react and respond accordingly to an alarm.
- The administrator and/or designee will evaluate new hires and agency staff prior to beginning their shifts on policies and procedures for dealing with elopements, resident with elopement risk, alarming doors and how to react and respond accordingly to an alarm.
- The charge nurse will evaluate any agency staff to ensure full understanding prior to beginning their shifts.
- The administrator and/or designee will provide additional monthly education on elopements, elopement risk residents, exit seeking behavior, alarms within the facility and how to properly respond to alarms within the facility to staff for the next 6 months.
- The DON (Director of Nursing) and/or designee will conduct random weekly audits of staff's knowledge on the policies and procedures on elopements, residents with elopement risk, alarming doors and how to react and respond accordingly for 8 weeks.
- The Policy on Elopement was revised to include attempted elopements and exit seeking behaviors and how to deal with exit seeking behaviors.
Failure to Supervise Wandering Resident Results in Serious Fall Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with dementia and cognitive communication deficits who was identified as a wanderer. The resident required staff supervision or assistance with walking and was known to wander, particularly at night. Despite being redirected multiple times by staff, the resident continued to walk into other residents' rooms. On the evening of the incident, the resident wandered into another resident's room and, during an interaction with that resident, fell and sustained a displaced fracture of the right femoral neck, which required surgical intervention. Staff interviews and record reviews revealed that the resident was frequently observed walking in and out of rooms and that staff attempted to redirect her several times without success. Staff acknowledged the difficulty in supervising the resident due to her persistent wandering behavior. The care plan and assessments documented the resident's risk for falls related to confusion and poor communication, as well as her need for supervision with ambulation. At the time of the incident, staff were engaged in routine rounds and preparing residents for bed. The resident was not under direct supervision when she entered another resident's room and fell. The incident report and staff statements indicated that the resident's wandering behavior was well known, and that staff interventions prior to the fall were limited to redirection and activity engagement, without the implementation of more intensive supervision measures.
Removal Plan
- Photos taken of all residents and made available at nurses' stations and the reception desk to identify residents 1-12 who are at risk for wandering.
- Additional staff, hall monitor, added to stay on the 2nd floor hall and visually observe and document observation of residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. During meal times, the monitoring of residents 1-12 will be handed off to CNA's and LPNs assigned to monitor the dining room and the hall monitor will remain on the hall to continue monitoring any of residents 1-12 that remain in their room for meals.
- Staff will be in-serviced on who the 12 residents are that are at risk for wandering, the need to visually observe residents 1-12 to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls, and methods for cueing, redirection, offering activities/snacks, and for what to do if a resident cannot be redirected.
- Hall monitor will be trained on residents 1-12 at risk for wandering. How to monitor residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. How to cue, redirect or offer activities/snacks, how to document on monitoring form, and how to handle meal time. Also trained on what to do if a resident cannot be redirected.
Failure to Protect Resident from Staff Sexual Abuse and Provide Immediate Protection
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to protect a resident from abuse and to ensure immediate protection following an incident involving a staff member. A certified nursing assistant (CNA) was witnessed by another CNA engaging in sexual intercourse with a resident who had aphasia but intact cognition. The witnessing CNA left the room to report the incident to a nurse, as per facility policy, but did not intervene or provide immediate protection to the resident while the act was ongoing. The facility's abuse prevention program did not include guidance for staff on immediate response to protect an alleged victim during and after an incident. Interviews with the administrator, DON, and corporate nurse revealed that staff had only been trained to report abuse to a nurse, not to intervene directly or remain with the resident to ensure their safety. The administrator did not initially recognize the incident as abuse due to the resident's apparent consent, and the facility did not report the incident as required. Further interviews confirmed that the CNA who witnessed the abuse followed existing policy, which was inadequate for immediate resident protection. The administrator and corporate nurse later acknowledged that staff should have been trained to intervene and stay with the resident in such situations. The lack of effective policies, staff training, and immediate protective actions led to the finding of Immediate Jeopardy.
Removal Plan
- Inservice training provided to the Administrator by the NHA Supervisor on the responsibilities of nursing facility staff to protect residents and recognize that any sexual relationship between staff and residents is considered abuse of power.
- All staff instructed to respond immediately to protect the alleged victim physically and psychologically during and after the investigation and to protect the integrity of the investigation.
- Victims of abuse to be examined for physical and psychological injuries and medically treated as indicated.
- Increased supervision of the alleged victim and residents as necessary, depending on the circumstances.
- Room and/or staffing changes to be made as necessary to protect the resident from the alleged perpetrator.
- Staff instructed to protect the victim from retaliation and provide emotional support and counseling during and after the investigation, as needed.
- Baseline competency interview completed with the Administrator to ensure understanding and retention of the inservice content, with immediate reinservice if any questions are answered incorrectly.
- QAPI monitoring implemented by interviewing random staff members to ensure staff awareness of immediate protection procedures during and after an abuse investigation.
- Effectiveness of corrective actions to be discussed at the QAPI Meeting, with findings added to the QAPI minutes and additional inservices or corrective actions implemented as needed.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and psychosocial harm by a staff member. A Certified Nursing Assistant (CNA), who was the primary caregiver for a resident with diagnoses including hemiplegia, hemiparesis, bipolar disorder, depression, and aphasia, engaged in sexual intercourse with the resident in his bed. The incident was directly observed by another CNA, who entered the room and witnessed the act taking place. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, confirmed during an interview that the sexual activity occurred and stated it was consensual. Despite the resident's cognitive status and his report of consent, the facility's staff failed to recognize that any sexual relationship between a staff member and a resident constitutes an abuse of power and is considered sexual abuse, regardless of apparent consent. The Administrator did not initially report the incident, stating he did not recognize it as abuse because it was consensual. The facility's abuse and neglect policy, which prohibits all forms of abuse including sexual abuse by staff, was not followed in this case. Interviews with staff confirmed that the CNA involved was immediately told to leave the facility after the incident was reported to nursing staff. The Director of Nursing and other administrative staff later acknowledged that the incident was sexual abuse and an abuse of power. The failure to recognize and report the incident as abuse, as well as the occurrence of the sexual act itself, constituted a deficiency in protecting residents from all forms of abuse as required by facility policy and federal regulations.
Removal Plan
- Review and update the facility's abuse and neglect policy to include statements clarifying that any sexual relationship between staff and residents is considered an abuse of power.
- Inservice the nursing facility staff on changes to the abuse and neglect policy and conduct baseline competency interviews.
- Remove the accused employee from the facility pending investigation.
- Examine the resident for injury and interview the resident.
- Interview the witness to the event.
- Interview the accused.
- Inservice all staff regarding abuse and neglect, including sexual abuse.
- Interview all interviewable residents to determine if they had witnessed or had a sexual encounter with a staff member.
- Physically examine all non-interviewable residents for any evidence of a sexual encounter.
- Conduct staff interviews to determine if they had witnessed or had knowledge of any staff sexual encounters.
- Assign two employees to care for the resident.
- Notify the resident's responsible party and nurse practitioner of the situation.
- Meet with the resident council to discuss concerns regarding the incident and encourage residents to report any issues.
- Make medication changes for the resident as indicated by the nurse practitioner.
- Terminate the accused from the facility.
- Have the facility psych nurse practitioner visit the resident and have the social services director reach out to in-house counseling services to determine eligibility for counseling related to the event.
- Implement monitoring of residents and staff using a post-event monitor and ask questions to determine if any inappropriate staff sexual behavior had been witnessed or suspected; continue monitoring until compliance is assured.
- Discuss the event and corrective actions at the QAPI meeting, and implement any corrective actions based on the interviews.
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