Allen Oaks Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakdale, Louisiana.
- Location
- 909 East 6th Avenue, Oakdale, Louisiana 71463
- CMS Provider Number
- 195584
- Inspections on file
- 25
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Allen Oaks Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility did not follow the posted menu for residents on a puree diet, as bread and dessert items were not pureed nor were appropriate alternatives consistently provided. The Dietary Manager confirmed that cooks did not puree bread or offer substitutes, resulting in the menu not being fully followed for all residents on puree diets.
Surveyors identified multiple deficiencies in food storage, kitchen sanitation, and staff hygiene, including unlabeled and unsealed food items, improper storage of dry goods, dirty dishware stored incorrectly, and a dietary aide not using a beard restraint. These failures had the potential to affect all residents in the facility.
The facility did not maintain an effective pest control program, as multiple flies were observed in the kitchen, including on food and food prep areas, and in a resident room. The Dietary Manager and administrator both acknowledged the ongoing fly problem, which had the potential to affect 72 residents.
A resident with an indwelling urinary catheter was observed on multiple occasions with their urinary drainage bag visible and without a privacy cover. The resident, who was cognitively intact and had multiple medical conditions, had a physician's order for catheter care. An LPN confirmed that the drainage bag should have been covered but was not, resulting in a failure to maintain the resident's dignity.
A resident with severe cognitive impairment and a history of falls did not have their walker accessible as required by their care plan. Observations showed the resident ambulating without the walker, and staff confirmed the device had not been present for at least a week, contrary to facility policy and the resident's assessed needs.
A resident with significant medical needs did not receive enteral feedings at the rate ordered by the physician. Observation revealed the tube feeding was set at 50 ml/hour instead of the prescribed 40 ml/hour. Facility staff, including an LPN, ADON, and DON, confirmed the feeding should have been administered at the lower rate as per the updated physician order.
A resident with COPD and dependence on supplemental oxygen was observed receiving oxygen at 3.5 L/min via nasal cannula, despite a physician's order for 2 L/min. The resident reported that staff did not check the oxygen flow rate, and observations confirmed the discrepancy on multiple occasions, indicating a failure to follow physician orders and facility policy for respiratory care.
Nursing staff failed to follow required procedures for wasting and documenting controlled substances. In one case, a nurse wasted a Tramadol tablet without a witness signature, and in another, a Hydrocodone/APAP tablet was improperly returned to its blister pack after being opened. The DON confirmed that staff are aware of the correct protocols, but these were not followed.
Expired Hydrocortisone and Clobetasol creams were found available for use in a medication room, with an LPN and the DON confirming they should have been disposed of. Additionally, a narcotic destruction locked box containing controlled substances was not permanently affixed and was stored in a shared office accessible to multiple employees, as confirmed by the ADON.
The facility did not ensure proper infection control practices, including the sanitary storage of clean care items and the implementation of Enhanced Barrier Precautions for a resident with a dialysis catheter. Clean items were stored inappropriately near soiled linen, used care items were returned to clean linen carts, and staff failed to use required PPE, despite active orders and care plan instructions.
A facility failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses, including a history of drug abuse. The care plan lacked necessary interventions beyond addressing synthetic THC gummies found, despite the resident's need for extensive assistance and intact cognition. An LPN confirmed the care plan's inadequacy.
A resident with a history of drug abuse and depression was given THC gummies by the DON without consulting the physician, leading to intoxication and hospitalization. The resident had requested marijuana, and the DON, after consulting with the Administrator, provided THC gummies. The physician was not informed until after the resident's hospitalization.
A resident with a history of drug abuse and major depressive disorder expressed suicidal ideations and was found with THC gummies, which were provided by the DON without physician consultation. The facility failed to follow protocol by not notifying the physician promptly or placing the resident on one-on-one monitoring, leading to a deficiency in care.
A cognitively impaired resident with a history of wandering exited the facility unsupervised on two occasions, despite having a wander alarm and being on an hourly monitoring schedule. The facility failed to post required signage and did not document the hourly monitoring. Video footage showed the resident leaving without staff presence, and staff interviews revealed a lack of awareness and documentation regarding the incidents.
A resident with severe cognitive impairment exited the facility unsupervised on two occasions. The facility failed to complete incident reports, investigate the elopements, or update the resident's care plan with new interventions. The DON did not consider these incidents as elopements since the resident did not leave the facility grounds, and there was no policy for staff training on elopement risks or responses.
A resident with severe cognitive impairment was verbally and mentally abused by a CNA during a night shift. The abuse, captured on video, included derogatory comments and profanity, causing harm to the resident. Another CNA present confirmed the inappropriate behavior, and the facility's administration acknowledged the abuse after reviewing the footage.
A resident with severe cognitive impairment was roughly handled by a CNA, who let the resident fall back onto the mattress while adjusting her gown. The CNA also used her cell phone on speaker during care, ignoring the resident's attempts to communicate. This violated the facility's policy on treating residents with dignity and respect.
A resident with Alzheimer's and other disorders, assessed as high risk for wandering, eloped twice from the facility. Despite these incidents, the care plan was not updated with new interventions. Interviews with the DON and ADM confirmed awareness of the elopements but acknowledged that no additional measures were implemented to prevent further occurrences.
A resident with severe cognitive impairment was improperly handled during transfers and bed mobility in an LTC facility. CNAs failed to follow proper protocols, resulting in rough handling during a transfer to a geri-chair and unsafe repositioning in bed. These actions were captured on video, highlighting deficiencies in care and adherence to the resident's care plan.
A facility failed to maintain proper infection control practices during resident care. A CNA was observed providing perineal care while standing on a mattress and improperly disposing of soiled items. The CNA also stood on a resident's bed to reposition her, contrary to safe and sanitary practices. The resident had severe cognitive impairment and required significant assistance with personal hygiene.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents and did not maintain a water management program to reduce the risk of Legionella. The DON confirmed the absence of EBP policies, and the Administrator acknowledged the lack of a water management plan and failure to check for Legionella.
A facility failed to provide necessary behavioral health care for a resident with a history of substance abuse and related disorders. The resident exhibited threatening behaviors and possessed dangerous items, but the facility did not document these incidents or provide psychiatric services. Staff reported feeling unsafe, and the resident was eventually placed on 1:1 supervision and transferred to a behavioral hospital.
The facility failed to check the placement and gastric residual volume (GRV) for a resident before administering enteral feeding, contrary to its policy. The resident, who had severe cognitive impairment and multiple diagnoses, was reconnected to her tube feeding without the necessary checks, as confirmed by an LPN and the Director of Nursing.
A facility failed to provide proper respiratory care for a resident with severe cognitive impairment and multiple diagnoses, including COPD. The resident's nebulizer mouthpiece was found undated and improperly stored, and an LPN confirmed that the equipment should have been dated and labeled weekly by the weekend ward clerk.
The facility failed to ensure proper communication and coordination with a dialysis facility for a resident requiring dialysis. The nursing staff did not send or receive communication sheets for the resident's dialysis appointments, and the dialysis facility did not complete the necessary documentation.
Failure to Follow Puree Diet Menu and Provide Alternatives
Penalty
Summary
The facility failed to meet the nutritional needs of residents on a puree diet by not following the posted menu and not providing appropriate alternatives for all menu items. Observations and interviews revealed that while the lunch menu included meatloaf, black-eyed peas, cauliflower and cheese, dinner roll, and lemon glazed cake, only the meatloaf, black-eyed peas, and cauliflower and cheese were pureed for residents on a puree diet. The cook confirmed that the glazed cake was not pureed and that pudding was provided as an alternative for all puree diets. Additionally, dinner rolls were not pureed, nor was an alternative provided for bread when it was served. The Dietary Manager confirmed that cooks did not puree bread or provide an alternative for bread for residents on puree diets, and acknowledged that the menu was not followed for these residents. Facility policies require that menus meet the nutritional needs of residents and that if a food group is missing, an alternate means of meeting nutritional needs should be provided. These requirements were not met for the five residents receiving a puree diet, as the menu was not fully followed and appropriate alternatives were not consistently provided.
Deficient Food Storage, Sanitation, and Staff Hygiene in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not store food in accordance with professional standards for food service safety. Observations revealed that food items in both the refrigerator and freezer, such as a 1-gallon bag of chicken nuggets and a tub of mayonnaise, were left open and undated. Additionally, dry food items like a 50-pound bag of pinto beans and a small bag of powdered creamer were found open, undated, and not stored in sealed containers. A scoop was also found stored inside a flour container, contrary to safe food handling practices. Further deficiencies included improper storage and cleanliness of dishware, with plates stored face up, some visibly dirty, and one plate containing paperclips. Clean dishware was not stored facedown as required. Staff were also observed not following hygiene protocols, as one dietary aide with facial hair was not wearing a beard restraint. These failures had the potential to affect all 72 residents residing in the facility.
Failure to Maintain Effective Pest Control Program Resulting in Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, which states that the building should be kept free of insects and rodents. Multiple observations over several days revealed the presence of numerous flies in the kitchen area, including flies landing on food being prepared and on food preparation surfaces. These observations were made in the presence of the Dietary Manager, who confirmed the ongoing fly problem and acknowledged that the kitchen should be free of pests. Additional observations found multiple flies present in a resident room on two separate occasions. The facility administrator also acknowledged the current issue with flies in the building. A total of 72 residents were potentially affected by the facility's failure to control the fly infestation, as the pest issue was observed in both food preparation areas and resident living spaces.
Failure to Provide Privacy Cover for Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided with a privacy cover for the catheter's urinary drainage bag. The resident, who had diagnoses including secondary malignant neoplasm of the liver, hypospadias, neuromuscular dysfunction of the bladder, and was receiving palliative care, was observed on two separate occasions in their room with the catheter drainage bag visible and uncovered. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a physician's order for catheter care every shift. During both morning and afternoon observations, the urinary drainage bag was seen containing urine and lacking a privacy cover. In an interview, an LPN confirmed that the drainage bag should have had a privacy cover but did not at the time of observation. The failure to provide a privacy cover for the urinary drainage bag did not honor the resident's right to dignity and respect, as required by facility policy and regulatory standards.
Failure to Provide Resident with Required Assistive Device
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, heart failure, and difficulty walking, did not have access to their prescribed assistive device, a walker. The resident's care plan indicated they were a fall risk with a history of two recent falls and required the use of a walker for safe ambulation. Observations on multiple occasions revealed the resident ambulating in their room without supervision or a walker, and the walker was not present in the room during these times. Further review and staff interviews confirmed that the walker had not been seen with the resident for at least a week, and staff were unsure of its location. The facility's policy required that assistive devices be provided, maintained, and accessible to residents based on their care plan and comprehensive assessment. Despite these requirements, the resident was left without the necessary assistive device, resulting in a failure to reasonably accommodate their needs and preferences.
Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical diagnoses, including pneumonitis due to inhalation, COPD with acute exacerbation, heart failure, cerebral infarction, and aphasia, did not receive enteral feedings as ordered by the physician. The resident, who was dependent for all activities of daily living and had a BIMS score of 0, was admitted with a physician's order for Osmolite 1.2 to be administered at 40 ml/hour via pump, with a corresponding care plan intervention. During observation, it was found that the tube feeding was infusing at 50 ml/hour instead of the ordered 40 ml/hour. Interviews with facility staff, including an LPN, the ADON, and the DON, confirmed that the feeding rate should have been 40 ml/hour as per the physician's order, and that the order had been updated during physician rounds. The failure to administer the enteral feeding at the prescribed rate constituted a lack of adherence to professional standards of quality care.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary care and services for respiratory care in accordance with professional standards for a resident requiring continuous oxygen therapy. According to the physician's order, the resident was to receive continuous oxygen at 2 liters per minute via nasal cannula due to diagnoses including COPD with acute exacerbation, other lung disorders, dependence on supplemental oxygen, and dyspnea. The resident's care plan also specified continuous oxygen at all times. However, multiple observations revealed that the resident was receiving oxygen at 3.5 liters per minute, which was not in accordance with the physician's order. Additionally, the resident reported that no staff checked the oxygen flow rate to ensure it matched the prescribed amount. The facility's policy required verification of physician orders and ongoing assessment before and during oxygen administration, but there was no evidence that staff were monitoring or adjusting the oxygen flow as ordered. This failure to follow physician orders and facility policy resulted in the resident receiving a higher oxygen flow rate than prescribed.
Failure to Follow Proper Procedures for Wasting and Documenting Controlled Substances
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and accurate handling of controlled substances for its residents. Specifically, on one medication cart, a nurse documented the wasting of a Tramadol tablet for a resident but did not obtain the required witness signature, as mandated by facility policy. The policy requires that the destruction of controlled substances be witnessed and documented by at least two staff members. The LPN involved confirmed that the witness signature was missing for the wasted medication. Additionally, another incident involved a resident's Hydrocodone/APAP tablet, which was removed from its blister pack but not administered. Instead of properly wasting the tablet according to protocol, the nurse taped the tablet back into the packaging, which is not permitted by facility policy. The DON confirmed that nurses are aware of the correct procedures, which include never returning a tablet to the packaging after it has been opened and always having two nurses witness and document the destruction of controlled substances. These failures resulted in non-compliance with both facility policy and regulatory requirements for the handling and documentation of controlled substances.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
Expired medications were found available for use in one of the facility's medication rooms. Specifically, an opened and used tube of Hydrocortisone cream and a tube of Clobetasol Propionate 0.05% cream, both past their expiration dates, were observed in Med Room B. The LPN present at the time confirmed that these expired creams should have been disposed of but were not, and the Director of Nursing acknowledged that expired medications should not be available for use in the medication room. Additionally, controlled substances awaiting destruction were not stored in accordance with facility policy and regulatory requirements. The narcotic destruction locked box, which contained multiple medication cards and bottles of controlled substances, was found on a shelf in a shared office and was not permanently affixed to any surface. The Assistant Director of Nursing confirmed that the box was not secured as required and that other employees had access to the shared office where the box was stored.
Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the storage and handling of resident care items and the implementation of Enhanced Barrier Precautions (EBP). On Hall Z, clean water basins were observed stored unbagged on a shelf in the dirty linen closet, next to overflowing soiled linen, which was confirmed by laundry staff as inappropriate and a risk for cross-contamination. Additionally, opened and used resident care items, such as wipes and denture cups containing baby powder, were found on the clean linen cart instead of being left in residents' rooms as required. Staff interviews confirmed that some employees habitually returned used items to the clean linen cart, and a used bottle of skin and hair cleanser was also found on the cart. The facility also failed to implement EBP for a resident with an indwelling dialysis catheter, despite active physician orders and care plan interventions specifying the need for EBP. Observations revealed no EBP signage or PPE caddy outside the resident's room, and both the resident and staff confirmed that only gloves were used during care, with no gowns applied. Interviews with CNAs and an LPN demonstrated a lack of awareness regarding the resident's EBP status, and facility leadership acknowledged that EBP was not in place as required.
Deficiency in Comprehensive Care Plan Development
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, major depressive disorder, insomnia, and type 2 diabetes mellitus, had a BIMS score indicating intact cognition and required extensive assistance for bed mobility, transfers, and toilet use. Despite having a history of drug abuse noted on admission, the care plan only included an intervention related to synthetic THC gummies found on 08/22/2024, without additional interventions to address the resident's needs. This oversight was confirmed during an interview with an LPN MDS, who acknowledged that the care plan should have included more comprehensive interventions.
Failure to Consult Physician Before Administering THC Gummies
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering THC gummies to a resident without consulting the resident's physician. The resident, who had a history of drug abuse and was diagnosed with major depressive disorder, hemiplegia, hemiparesis, insomnia, and type 2 diabetes mellitus, was found to be lethargic and with slurred speech after consuming the gummies. The resident's care plan noted a history of drug abuse and depression, with interventions in place to monitor mood and behavior. Despite these precautions, the resident was given THC gummies by the Director of Nursing (DON) without prior consultation with the physician. The incident began when the resident expressed feelings of depression and requested marijuana from the DON, who instead offered to procure THC gummies. The DON consulted with the Administrator, who approved the purchase, believing it was legal. The DON subsequently bought a container of 10 THC gummies and gave them to the resident. The resident consumed some of the gummies, leading to a state of intoxication, which was observed by staff who found the resident's room in disarray with food and items scattered on the floor. The physician was not informed of the resident's request for marijuana or the subsequent provision of THC gummies until after the resident was hospitalized for psychiatric evaluation. The physician confirmed that he would not have approved the use of THC gummies and was unaware of the situation until after the resident's hospitalization. Interviews with staff revealed a lack of communication and failure to follow proper protocols, resulting in the resident's adverse reaction and subsequent hospitalization.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder, resulting in a deficiency. The resident, who had a history of drug abuse and was diagnosed with major depressive disorder, expressed suicidal ideations and was found with synthetic THC gummies. Despite these clear signs of distress, the facility staff did not follow the established protocol for handling such situations. The resident's physician was not notified promptly, and the resident was not placed on one-on-one monitoring as required by the facility's policy. The deficiency was further compounded by the actions of the Director of Nursing (DON), who purchased THC gummies for the resident without consulting the physician. This decision was made after the resident requested marijuana, and the DON, after consulting with the Administrator, decided to provide the gummies. This action was taken without considering the potential impact on the resident's mental health condition, which was already compromised. The situation escalated when the resident expressed suicidal thoughts and exhibited erratic behavior, including tearing up her room. Despite these alarming signs, the staff failed to take immediate action, such as notifying the physician or placing the resident under close supervision. It was only after the resident was sent to the hospital for psychiatric evaluation that the full extent of the oversight became apparent, highlighting a significant lapse in the facility's duty to ensure the resident's safety and well-being.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident with a history of wandering, resulting in the resident exiting the building unsupervised on two occasions. The resident, who had severe cognitive impairment and was at high risk for wandering, managed to leave the facility through the front entrance by following visitors out. This occurred despite the resident having a wander/elopement alarm and being on an hourly monitoring schedule, which was not documented as being followed. The resident's medical records indicated a high risk for wandering, with a history of attempting to leave the facility without informing staff. The care plan included interventions such as coded locks on doors, hourly monitoring, and signage to prevent residents from exiting without staff approval. However, observations revealed that the required signage was not posted, and there was no evidence of hourly monitoring being conducted. Interviews with staff confirmed that the resident was able to exit the facility quickly and that no new interventions were implemented after the incidents. The facility's video footage showed the resident leaving the building unsupervised on both occasions, with no staff present in the lobby at the time. Staff interviews revealed a lack of awareness and documentation regarding the resident's monitoring and the incidents were not considered elopements by the facility, as the resident did not leave the facility grounds. This lack of recognition and response to the incidents contributed to the deficiency in providing adequate supervision to prevent accidents.
Failure to Prevent Resident Elopement and Inadequate Incident Reporting
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of a resident with severe cognitive impairment and a history of wandering. This resident exited the building unsupervised on two occasions, following visitors out through the front entrance and into the parking lot. The facility did not have an effective system in place to supervise the resident adequately, which led to these incidents. Additionally, the facility did not complete incident reports or thoroughly investigate the elopements. The resident's care plan was not updated with new interventions to prevent further unsupervised exits. Interviews with the Director of Nursing (DON) revealed that the facility did not consider these incidents as elopements because the resident did not leave the facility grounds. Furthermore, there was no policy in place for training staff on elopement risks or responses, nor were there any in-services conducted following the incidents.
Verbal and Mental Abuse of Resident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member, resulting in actual harm. The incident involved a resident with severe cognitive impairment, diagnosed with Dementia and Major Depressive Disorder, who was verbally abused by a CNA during the night shift. The abuse was captured on video footage, where the CNA made derogatory and demeaning comments to the resident, including calling them a 'meanie' and comparing their behavior to 'loving the Devil.' The resident, who had a history of attending church services and listening to Christian music, was subjected to further verbal abuse when the CNA used profanity and likened the resident's actions to that of an animal. The resident's daughter confirmed that such language would have been deeply upsetting to her mother, who was raised in a religious environment. The facility's policy on abuse and neglect clearly states that all residents should be free from any form of abuse, including verbal and mental abuse, irrespective of their mental or physical condition. The incident was corroborated by another CNA who was present during the abuse. This CNA provided a written statement and a telephone interview, confirming the inappropriate comments made by the offending CNA and the resident's apparent fear. The facility's administration reviewed the video footage and confirmed the occurrence of verbal and mental abuse, acknowledging the failure to protect the resident from such treatment.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by video footage and interviews. A resident with severe cognitive impairment, who required assistance with daily living activities, was subjected to rough handling by a CNA. The CNA was observed roughly turning the resident and letting her fall back onto the mattress while adjusting her gown. This action was contrary to the facility's policy, which emphasizes treating residents with dignity and respect, and assisting them in maintaining their self-esteem and self-worth. Additionally, the same CNA was observed using her cell phone on speaker while providing care to the resident, ignoring the resident's attempts to communicate. The CNA continued her phone conversation, failing to acknowledge the resident, which is a violation of the facility's policy that requires staff to keep residents informed and oriented to their environment. The CNA later confirmed during an interview that she used her cell phone while providing care, acknowledging that it was inappropriate.
Failure to Update Care Plan After Resident Elopements
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as Resident #R7, following two elopement incidents. Resident #R7, who was admitted with diagnoses including Alzheimer's Disease, Schizoaffective Disorder, and Bipolar Disorder, was assessed as being at high risk for wandering. Despite this, the facility did not update the resident's care plan with new interventions after the resident eloped on two separate occasions. The existing care plan included measures such as coded locks, hourly monitoring, and signage for visitors, but these were not revised following the incidents. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that no additional interventions were implemented after the elopements. The DON acknowledged that Resident #R7 had left the facility unsupervised on two occasions, and the ADM confirmed awareness of these events but admitted that the care plan had not been updated to prevent further elopements. This lack of action represents a failure to adequately address the resident's risk of elopement, as no new strategies were put in place to mitigate this risk after the incidents occurred.
Improper Transfer and Bed Mobility Techniques
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident, as evidenced by improper handling during transfers and bed mobility. The resident, who had severe cognitive impairment and required extensive assistance with activities of daily living, was subjected to rough handling by CNAs during a transfer to a geri-chair. The CNAs did not follow proper transfer protocols, resulting in the resident being abruptly placed in the chair, which was not positioned correctly for a safe transfer. This incident was captured on video by the resident's family, highlighting the improper technique used by the CNAs. In another incident, a CNA was observed standing on the resident's bed to reposition her, which was against the facility's protocol for a two-person assist. The CNA's actions were captured on video, showing her standing on an unstable surface and pulling the resident up in bed, causing the resident to express discomfort. The CNA admitted to rushing the process and not following the correct procedure, which required moving the mattress and lowering the bed for a safer repositioning. These incidents demonstrate a failure to adhere to the resident's care plan and proper transfer techniques, compromising the resident's safety and dignity. The facility's staff did not anticipate and meet the resident's needs as outlined in her care plan, which included ensuring safe and gentle handling during transfers and bed mobility. The improper actions of the CNAs were documented through video evidence and staff interviews, confirming the deficiencies in care provided to the resident.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper perineal care provided to a resident. The staff did not adhere to the facility's policy on perineal care, which requires washing the perineal area from front to back and discarding disposable items into designated containers. Video footage revealed that a CNA provided perineal care while standing on a mattress on the floor next to the resident's bed, and improperly disposed of soiled linens and briefs by placing them on the mattress and floor. Additionally, the CNA was observed standing on the resident's bed to reposition her, which is not a safe or sanitary practice. The resident involved had severe cognitive impairment and required significant assistance with personal hygiene and toileting. The facility's administrator confirmed that the CNA should not have stood on the resident's bed and acknowledged that the CNA was in a rush, which contributed to the improper care provided.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) for residents where indicated. Observations on two separate days revealed the absence of EBP for residents throughout the facility. The Director of Nursing (DON) confirmed that there was no policy or procedure for EBP and that no residents were placed on EBP as indicated. Additionally, the facility did not maintain a water management program to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the water system. The Administrator confirmed that the facility lacked a plan for when control limits are not met and that the maintenance staff had failed to check the water for Legionella.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of opioid abuse, psychoactive substance abuse, and other related disorders. The interdisciplinary team did not thoroughly evaluate the resident's behavioral symptoms or implement a plan of care to address the severity, distress, and potential safety risks. Despite physician orders to document behaviors every shift and provide specific medications, there was no documentation that the resident was assessed by a psychiatric provider or received psychiatric services over a significant period. The resident exhibited concerning behaviors, including possession of a box cutter and a knife, and made threatening comments to staff members. These incidents were reported to the facility's administrator, who did not document the events in the resident's medical records or contact the resident's physician. The administrator believed the situation was resolved without further action, despite the resident's continued inappropriate and threatening behavior towards staff. Interviews with staff members revealed that the resident's behavior made them feel uncomfortable and unsafe. The facility's failure to address these behaviors and provide appropriate psychiatric care resulted in the resident being placed on 1:1 supervision and eventually transferred to a behavioral hospital. The lack of timely and adequate intervention highlights a significant deficiency in the facility's behavioral health care services.
Failure to Check Placement and GRV for Enteral Feeding
Penalty
Summary
The facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not check the placement and gastric residual volume (GRV) for a resident before administering enteral feeding. The facility's policy requires checking the pH of aspirate and measuring GRV with at least a 60 mL syringe to prevent aspiration and assess tolerance of enteral feeding. However, these procedures were not followed for Resident #45, who had severe cognitive impairment and multiple diagnoses, including cerebral infarction, heart failure, epilepsy, dementia, and chronic kidney disease. On the day of the incident, Resident #45 had been out of the facility on pass and returned around 1:20 p.m. The resident's responsible party notified the staff that the resident needed to be reconnected to her tube feeding. An LPN entered the resident's room, cleaned the feeding tube connection, and connected the tubing to the resident's PEG without checking for placement or residual. The LPN confirmed in an interview that she did not perform these checks but acknowledged that she should have. The Director of Nursing also confirmed that the LPN should have checked the placement before initiating the enteral feeding.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, Chronic Obstructive Pulmonary Disease (COPD), Sarcopenia, and Sleep Apnea. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution to be administered every six hours as needed for shortness of breath and congestion. However, observations revealed that the resident's nebulizer mouthpiece was improperly stored in an undated Ziploc bag on her bedside table, and the mouthpiece itself was also undated. Interviews and further observations confirmed that the nebulizer equipment was not dated or labeled as required. An LPN confirmed the findings and stated that the weekend ward clerk was responsible for dating and labeling the oxygen equipment weekly, but this had not been done. This failure to properly date and label the respiratory equipment represents a deficiency in the facility's respiratory care practices.
Failure to Ensure Proper Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who had diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Heart Failure, was readmitted with physician's orders to receive dialysis three days per week. However, the facility did not maintain ongoing communication, coordination, and collaboration with the dialysis facility. Specifically, the dialysis communication sheets were not completed by the dialysis facility, and the nursing staff did not send or receive these sheets for the resident's dialysis appointments. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the communication sheets were not being filled out by the dialysis facility, and the nursing staff did not contact the dialysis nurse to communicate the dialysis care received. The dialysis facility's RN confirmed that the nursing facility did not send communication sheets with the resident, which would have been filled out at each dialysis appointment. The DON acknowledged that the communication sheets should have been completed with each dialysis visit but were not.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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