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)
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.
Latest Citations in Louisiana
The facility failed to consistently monitor and document fluid intake for a resident with orders for intake and output, resulting in multiple days without required documentation or meeting minimum fluid requirements. Additionally, after a resident experienced significant weight loss and a change in nutritional status, the facility did not notify the RD as required, and there was no evidence of an RD evaluation or referral. These actions did not comply with facility policies for hydration and nutrition monitoring.
The facility did not store or label food items in accordance with professional standards, including leaving opened dry and refrigerated foods unsealed and unlabeled, and storing potentially hazardous snacks such as sandwiches in an unmonitored, non-temperature-regulated cooler overnight. These deficiencies were confirmed by dietary staff and had the potential to affect all residents receiving meals.
Staff failed to follow Enhanced Barrier Precautions during a resident transfer involving a PEG tube, did not maintain a sanitary laundry department with excessive lint and dust, and a treatment nurse contaminated wound care supplies by placing gauze on a computer keyboard before using it on a resident with an open toe wound.
The facility did not maintain an effective pest control program, leading to the presence of flies and gnats in resident rooms, the dining area, and the kitchen. Multiple residents reported frequent encounters with pests, and staff confirmed ongoing issues, with direct observations of flies in food service areas and during meals.
The facility did not report two separate incidents—one involving alleged physical abuse by a CNA and another involving a resident's elopement—within the required two-hour timeframe after becoming aware of the events. In both cases, the administrator acknowledged the delay in reporting to the State Survey Agency, which did not comply with established policy and regulatory requirements.
A resident with moderate cognitive impairment and a language barrier was not provided with a communication board as required by their care plan. Staff confirmed the absence of any communication aid and relied on gestures and guessing to communicate with the resident, despite the documented need for such support.
The facility did not post the results of three recent surveys, making only the previous annual survey results accessible to residents. This was confirmed by the administrator, who acknowledged that the more recent survey outcomes, which included deficiencies, were not available for resident review.
The facility did not obtain or document informed consent for the use of psychotropic medications for five residents with various psychiatric and medical conditions. Despite some residents being cognitively intact and capable of providing consent, staff confirmed that no consents were present in the medical records for medications such as antipsychotics, antidepressants, and antianxiety agents.
Several residents did not have accurate MDS assessments, with omissions including unreported pressure ulcers, falls, and wounds. Required quarterly risk assessments for skin and falls were not completed as scheduled. Staff interviews and record reviews confirmed that these inaccuracies and missed assessments did not reflect the residents' true clinical status.
Several residents with significant medical and cognitive needs did not receive adequate assistance with bathing and personal hygiene, including nail and facial hair care. Observations and interviews revealed that residents had long, dirty fingernails or lengthy facial hair, and documentation showed that scheduled baths were frequently missed without record of refusals or alternative care. Nursing staff and the DON confirmed these deficiencies during the survey.
Failure to Monitor and Intervene for Resident Hydration and Nutrition
Penalty
Summary
The facility failed to implement and monitor interventions to maintain proper hydration and nutrition for two residents. For one resident with diagnoses including anorexia, diabetes, major depressive disorder, and acute kidney failure, there was a physician's order to monitor intake and output every shift with a minimum daily fluid intake of 1500cc/ml. However, review of documentation over a 30-day period revealed multiple days where nursing staff and CNAs did not document fluid intake every shift as ordered, and several days where the recorded intake did not meet the minimum requirement. The Director of Nursing confirmed these findings, acknowledging that the required monitoring and documentation were not consistently performed. For another resident with acute and chronic respiratory failure, severe protein-calorie malnutrition, and a history of significant weight loss, the facility failed to notify the Registered Dietician (RD) of a substantial change in nutritional status. The resident experienced a 19-pound weight loss in one month following hospitalization and new PEG tube placement. Although the care plan indicated a referral to the RD for evaluation due to the significant weight loss, there was no evidence in the medical record that such a referral or evaluation occurred. The RD confirmed she did not receive any request for evaluation regarding the resident's weight loss, and the DON could not provide documentation of a referral or evaluation being sent. Facility policies required monitoring and documentation of intake and output for residents with physician orders, as well as prompt RD consultation for significant weight changes. In both cases, the facility did not follow its own policies or physician orders, resulting in a failure to ensure adequate hydration and nutrition monitoring and intervention for the affected residents.
Failure to Store and Label Food Items According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a kitchen tour and confirmed through staff interviews. Specifically, an opened 20-pound box of spaghetti noodles was found in the pantry without a sealed container or an open date label. In the freezer and coolers, a two-gallon zip lock bag of waffles and a bag of liquid eggs were not labeled with open dates, and a 15-pound box of bacon was left open to air. These practices were not in compliance with the facility's own policies, which require all food items to be tightly wrapped, labeled, and stored in sealed containers to prevent contamination. Additionally, the facility did not appropriately store potentially hazardous snacks. Sandwiches containing turkey and pimento cheese were prepared and stored in a portable ice cooler on a hydration cart from the evening until the following morning, without temperature regulation or monitoring. The dietary manager confirmed that the cooler was not temperature regulated and that temperatures were not being monitored during this period, despite the presence of potentially hazardous foods. These deficiencies had the potential to affect all residents receiving meals from the kitchen.
Infection Control Failures in EBP, Laundry Sanitation, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In one instance, staff did not follow Enhanced Barrier Precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. Although the resident had physician orders and a care plan indicating the need for EBP, including gown and glove use during direct care activities such as transfers, a certified nursing assistant (CNA) was observed transferring the resident without wearing a gown, despite EBP signage and available personal protective equipment (PPE) at the room. Additionally, the facility's laundry department was found to be unsanitary, with excessive lint and dust present in and around the dryers, on the walls, and hanging from the ceilings. The administrator confirmed that the laundry area was not maintained in a clean and sanitary condition, as required for infection control. A further deficiency was observed during wound care for a resident with multiple comorbidities, including diabetes, chronic kidney disease, and an open wound on the left great toe. The treatment nurse contaminated a 4x4 gauze by placing it on a computer keyboard and then used the contaminated gauze during wound care, rather than discarding it. The nurse acknowledged the error, confirming that the wound care supplies were not kept sterile during the procedure.
Failure to Maintain Effective Pest Control Program Resulting in Presence of Flies and Gnats
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats throughout the building, including resident rooms, the dining area, and the kitchen. Multiple residents reported seeing flies and gnats in their rooms and common areas, with one resident stating he had to purchase a fly swatter due to the frequency of pests. Observations confirmed flies flying in the dining room during meal times, with one resident swatting at a fly crawling on his soup bowl and another fly crawling on a dining table near a resident's plate. The facility's pest control policy required the use of various methods to control seasonal pests, but staff interviews and direct observations indicated these measures were not effective in preventing the presence of flies and gnats. Further observations in the kitchen revealed live flies present in the food preparation and kitchen areas on multiple occasions. The Maintenance Director acknowledged awareness of the ongoing issue with flying insects, particularly during the summer months, and described the use of sticky traps as a deterrent. The Dietary Manager also confirmed recent problems with live flies in the kitchen and acknowledged that the kitchen should always be free of pests, but this standard was not met.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and neglect to the State Survey Agency as required by its own policy and federal regulations. In the first instance, a resident with intact cognition alleged that a CNA had slapped him on the face. The facility became aware of this allegation at 8:30 a.m., but did not enter the incident into the SIMS reporting system until 1:29 p.m., exceeding the required two-hour reporting window for abuse allegations. The administrator confirmed that the report was not submitted within the mandated timeframe. In a separate incident, another resident with severe cognitive impairment and a history of elopement risk exited the facility through a bathroom window. The facility became aware of the elopement at 8:30 a.m., but did not report the incident in the SIMS system until 6:18 p.m., again failing to meet the two-hour reporting requirement. The administrator acknowledged that the elopement was not reported within the required timeframe. Both incidents demonstrate a failure to immediately report allegations of abuse and neglect as outlined in facility policy and regulatory requirements.
Failure to Provide Communication Aid for Non-English Speaking Resident
Penalty
Summary
A deficiency was identified when a resident with a language barrier and moderate cognitive impairment was not provided with a necessary communication aid as outlined in their care plan. The resident, who did not speak or understand English, was admitted with diagnoses including Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Dementia, and Generalized Anxiety Disorder. The care plan specifically indicated the need for a communication board to assist with communication due to the resident's difficulty understanding others. Despite this documented need, multiple observations and staff interviews confirmed that no communication board or aid was present in the resident's room. Staff members, including a CNA and an LPN, reported relying on gestures, pointing, and guessing to determine the resident's needs, as no communication aid was available. Both staff members acknowledged the resident's difficulty with English and confirmed that a communication board was not in use, despite its inclusion in the care plan.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of its most recent surveys were posted and accessible to residents. During an observation on 05/21/2025, it was found that only the results of the annual survey dated 05/08/2024 were available in the survey results binder for residents to view. However, the facility had undergone three additional surveys after the annual survey—on 09/26/2024, 04/01/2025, and 04/23/2025—which resulted in deficiencies, but the results of these surveys were not posted. This was confirmed during an interview with the facility administrator, who acknowledged that the results of the three subsequent surveys had not been made available to residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent for the use of psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents. Record reviews and staff interviews confirmed that for five residents with various diagnoses such as bipolar disorder, depression, dementia, schizophrenia, and schizoaffective disorder, there was no documented evidence of informed consent for the administration of these medications. The medications in question included Haldol, Seroquel, Escitalopram, Zyprexa, Clonazepam, Divalproex, Clozapine, Mirtazapine, Lorazepam, Sertraline, Depakote, and Geodon. Interviews with the Director of Nursing and the Regional Director of Clinical confirmed the absence of required consents in the residents' medical records. Some of the residents were noted to be cognitively intact based on their BIMS scores, indicating they were capable of providing consent. Despite this, the facility did not obtain or document consent for the use of psychotropic medications, as required, for any of the five residents reviewed.
Inaccurate MDS Assessments and Missed Risk Evaluations
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of several residents, resulting in multiple deficiencies. For one resident with a history of cerebrovascular disease, neuropathy, and dementia, the quarterly MDS did not document a stage 3 pressure ulcer that was present and facility-acquired, nor was a Braden scale risk assessment completed quarterly as required. Interviews with nursing staff and record reviews confirmed that the pressure ulcer was omitted from the MDS and that the last Braden assessment had not been updated for several months. Another resident with severe cognitive impairment and multiple comorbidities experienced two falls prior to the quarterly MDS assessment, but these incidents were not documented in the MDS. Additionally, the required quarterly fall risk assessment was not completed, with the last assessment dated several months prior. Staff interviews confirmed the omission of the falls from the MDS and the lack of timely risk assessment. A third resident with severe cognitive impairment suffered a fall resulting in a laceration and stitches, but the MDS inaccurately recorded the number of falls with injury. In another case, a resident with traumatic brain injury and reduced mobility had pressure ulcers on admission, but the quarterly MDS did not reflect the presence of these wounds. Staff interviews and record reviews consistently confirmed that the MDS assessments were inaccurate and did not align with the residents' actual clinical conditions.
Failure to Provide Adequate Bathing and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for residents who were unable to perform activities of daily living independently. Multiple residents with significant medical conditions and cognitive impairments were observed to have unmet hygiene needs, including inadequate bathing and nail care. For example, one resident with cerebrovascular disease and major depression, who was cognitively intact and required assistance with personal hygiene, was found to have long, dirty fingernails despite having requested staff assistance to trim them. A licensed practical nurse confirmed the need for nail care after direct observation. Another resident with severe obesity, diabetes, and multiple mobility issues, who required maximal assistance for bathing and hygiene, reported not receiving scheduled bed baths. Documentation confirmed that this resident received significantly fewer baths than scheduled, with no record of refusals or alternative care provided. The director of nursing verified the lack of documentation for missed baths. Similarly, a resident with dementia and muscle weakness, requiring substantial assistance, was observed on multiple occasions to have very long fingernails, which was acknowledged by the director of nursing during an in-room observation. Additionally, a resident with cerebral infarction, diabetes, and psychiatric diagnoses, who was cognitively intact and required substantial assistance with personal hygiene, was observed to have lengthy facial hair on multiple occasions. Bathing documentation for this resident was also incomplete, with only a few baths recorded over a two-month period despite a regular schedule. Staff interviews confirmed the expected bathing schedule, and the director of nursing acknowledged the lack of documentation for completed baths.
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