Golden Age Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Denham Springs, Louisiana.
- Location
- 27090 Hwy 16, Denham Springs, Louisiana 70726
- CMS Provider Number
- 195524
- Inspections on file
- 29
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Golden Age Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Unclean Resident Rooms and Bed Areas: Two residents were found with unsanitary room conditions, including a brown substance splattered on a wall behind one resident's bed and another resident's pillow without a pillow case, stained with red, brown, and yellow dried substances. Dried brown substance was also observed on both bed rails. The resident and family reported the conditions had been ongoing, and staff confirmed housekeeping and aide responsibilities for cleaning and linens.
Failure to Prime Insulin Pen Needles Before Insulin Administration: An LPN administered insulin to residents with DM using insulin pens without priming the pen needle first, despite manufacturer instructions requiring an airshot before each injection to ensure proper dosing. The LPNs confirmed the omission, and the DON stated priming insulin pen needles is standard of care.
Failure to Provide Scheduled Showers and Clean Attire: Three residents with ADL assistance needs did not receive required hygiene support. Two residents missed scheduled showers despite care plans and shower schedules, and a hospice resident with dementia remained in the same nightgown between baths instead of being dressed daily in clean attire. Interviews with CNA, family, and DON confirmed the missed showers and unchanged clothing.
Staff failed to demonstrate competency with insulin pen administration and respiratory equipment cleaning. Three LPNs gave insulin to three residents without priming the insulin pen needle, despite orders for insulin in residents with DM. Staff also cleaned a resident’s non-invasive ventilation mask using wipes, alcohol, and paper towels instead of the facility’s soap-and-water method, and the tubing was not cleaned; one LPN stated she had never received training on cleaning the mask and tubing.
Improper Cleaning of Non-Invasive Ventilation Equipment: A resident with COPD, chronic respiratory failure, and shortness of breath used an AVAPS-AE ventilator with a full face mask. The order required the mask to be cleaned every morning and air dried, and the facility policy required daily cleaning of the mask and tubing with warm water and soap. Staff instead reported cleaning the mask with personal cleansing wipes, alcohol wipes, or water-soaked paper towels, and they had not cleaned or changed the tubing.
Failure to Follow EBP and Glove Precautions During Resident Care: Staff did not consistently use EBP PPE during direct care for two residents with indwelling devices. An LPN provided PICC line care to one resident with only gloves and no gown, and an LPN and CNA provided catheter and incontinence care to another resident without gowns and without changing gloves after handling feces before touching a clean brief.
A resident with dementia and moderate cognitive impairment, requiring substantial ADL assistance, reported that a CNA was rough and consistently rude during care. Staff interviews confirmed the CNA displayed frustration and used an aggravated tone, with an LPN and the DON acknowledging the behavior was inappropriate and did not uphold the resident's right to dignity and respect.
A resident with a history of depression and prior sexual trauma was sexually abused by a visitor, who showed explicit images and forced non-consensual sexual contact in the resident's room. The incident was not immediately reported due to the resident's embarrassment, and staff did not observe any signs of distress or inappropriate behavior at the time. The abuse resulted in psychological harm, and the event only came to light after the resident disclosed it to staff, leading to law enforcement involvement.
A resident who was frequently incontinent of bowel had dried stool on the floor and bed sheet, which was not cleaned by staff. The CNA noticed the stool but did not clean it, and the administrator confirmed that nursing staff are responsible for maintaining a clean environment.
A resident with mental health diagnoses was admitted with a PASRR Level II determination, which included recommendations for Behavioral Health IOP, Crisis Planning, and Dementia Assessment. The facility failed to incorporate these recommendations into the resident's care plan, as confirmed by staff interviews. The oversight was acknowledged by the care plan nurse, social services director, MDS coordinators, and DON.
A resident who required assistance with showering did not receive scheduled showers for four days due to the absence of the shower aide and lack of action by hall CNAs. The facility's documentation confirmed the missed care, as no records were found for the scheduled shower.
The facility failed to ensure food was stored under sanitary conditions in unit refrigerators, as several items were found unlabeled during an inspection. An LPN confirmed that staff should label all outside food items with the resident's name and date, which was not done. The DON was informed and confirmed the labeling requirement.
A facility failed to accurately code a resident's MDS assessments for hospice care, despite physician orders indicating active hospice status. The resident, admitted with Adult Failure to Thrive, had incorrect MDS entries on two occasions, which were confirmed by the MDS Coordinator and the DON.
A facility failed to administer IV fluids according to professional standards for a resident with pneumonia and dehydration. The resident's IV site was not assessed, flushed, or documented daily, and was covered with an undated dressing. Staff confirmed the lack of proper monitoring and documentation, acknowledging the oversight.
A resident with severe cognitive impairment and multiple diagnoses was found to have a deformed leg by an LPN, who failed to report this significant change to the physician as required by the facility's policy. The NP and DON confirmed the lapse in communication, noting that the resident did not express pain, which may have influenced the LPN's decision not to report the condition.
The facility failed to implement physician's orders for two residents, resulting in a lack of a wheelchair alarm and visual cue for brakes for one resident, and the absence of TED hose for another. Staff confirmed these orders were not followed.
A resident with bilateral below-the-knee amputations and a history of falls was found on the floor, and a chair alarm was ordered as an intervention. However, the alarm was not implemented, as confirmed by staff interviews and observations, leading to a deficiency in maintaining a safe environment.
A resident requiring substantial assistance with bathing did not receive a scheduled bath, as confirmed by staff interviews and bath logs. The facility's policy required showers to be given as scheduled, but there was no documentation of a bath being administered on the missed date. Staff interviews revealed confusion over documentation responsibilities, leading to the deficiency.
A facility failed to maintain proper infection control practices during incontinence care for a resident. Two CNAs did not change gloves or perform hand hygiene after handling soiled linens and before touching clean items or the resident's belongings. Despite the facility's hand hygiene policy, the CNAs continued to use the same gloves throughout the care process, including when applying barrier cream and lotion. Interviews confirmed the CNAs' failure to adhere to hand hygiene protocols, and the DON acknowledged the lapse in proper procedure.
Unclean Resident Rooms and Bed Areas
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 residents reviewed for environment. One resident, admitted with diagnoses including Idiopathic Peripheral Autonomic Neuropathy, Chronic Ischemic Heart Disease, Morbid Severe Obesity due to Excess Calories, and Acute on Chronic Diastolic Congestive Heart Failure, had a Quarterly MDS showing a BIMS of 13, indicating she was cognitively intact. Observations of her room showed a brown substance splattered on the wall behind her bed on two separate occasions. The resident stated the substance had been on the wall for months and that she had asked staff to clean it, but no one had done so. A CNA confirmed the substance had been there, and housekeeping staff and the ADM stated it was housekeeping's responsibility to clean visible substances from residents' rooms and walls. The second resident, admitted with Alzheimer's Disease and a Quarterly MDS showing a BIMS of 5, indicating severe cognitive impairment, was observed with a pillow that had no pillow case and had multiple areas of red, brown, and yellow dried substances. Dried brown substance was also observed on both bed rails on two separate occasions. The resident's daughter stated that during most visits, the resident did not have a clean pillow case and the bed rails were not cleaned. The resident stated she wanted a pillow case because it was "nasty." Housekeeping staff confirmed cleaning the bed rails was housekeeping's responsibility, and CNAs stated it was the aide's responsibility to place clean linens on the bed, including the pillow case. The ADM stated he would get staff to get her a clean pillow immediately and confirmed housekeeping was responsible for cleaning the bed rails daily.
Failure to Prime Insulin Pen Needles Before Administration
Penalty
Summary
The facility failed to ensure nursing staff primed insulin pen needles before administering insulin, which was identified as not meeting the manufacturer’s instructions for use and the facility’s standard of care. Review of the insulin pen product insert showed the pen needle should be prepared and the pen primed according to the manufacturer’s instructions before selecting the dose, and the insulin pen instructions stated that an airshot should be given before each injection to ensure proper dosing. During observations, an LPN administered Insulin Aspart to a resident with Type 2 DM, Regular Insulin to another resident with Type 2 DM, and Insulin Aspart to a resident with Type 1 DM without priming the insulin pen needle first. Each LPN confirmed during interview that the pen needle had not been primed before the insulin was dialed up and given. The DON later stated that insulin pen needles should have been primed prior to administering the ordered dose and that priming was a standard of care.
Failure to Provide Scheduled Showers and Daily Clean Attire
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received necessary assistance to maintain good hygiene for three residents reviewed for ADLs. Resident #7, who had radiculopathy of the lumbar region and a BIMS score of 11 indicating moderate cognitive impairment, had a care plan directing staff to assist with bathing and a shower schedule of Tuesday, Thursday, and Saturday. Review of shower documentation showed she received only two showers during the week of 03/08/2026 and did not receive her scheduled shower on 03/14/2026. Resident #144, who had multiple sclerosis, a BIMS score of 14 indicating cognitive intactness, and required partial/moderate assistance with ADLs, also had a care plan directing staff to assist with bathing and a shower schedule of Tuesday, Thursday, and Saturday. Shower documentation showed she received only two showers during the weeks of 02/01/2026, 02/22/2026, and 03/08/2026, and did not receive showers on 02/07/2026, 02/28/2026, and 03/14/2026. During interview, Resident #144 stated she had not been receiving all of her scheduled showers and specifically reported missing the Saturday shower on 03/14/2026. Resident #98, who had age-related osteoporosis, transient cerebral ischemic attack, Alzheimer's disease, and was on hospice, had a BIMS score of 01 and a care plan directing staff to assist with dressing and hygiene. Family members stated hospice bathed her three times weekly, but she remained in the same nightgown between baths because staff were not changing her attire daily. Observations on multiple days showed Resident #98 wearing the same blue and white flower nightgown, and the hospice CNA confirmed she bathed the resident on 03/14/2026 and dressed her in that gown. The DON confirmed Resident #98 should be dressed daily in clean attire.
Staff Competency Deficiencies in Insulin Pen Use and Respiratory Equipment Cleaning
Penalty
Summary
The facility failed to ensure nursing staff had the competencies and skill sets needed to care for residents receiving insulin by insulin pen and a resident receiving non-invasive mechanical ventilation care. During observations, three LPNs administered insulin to three residents without priming the insulin pen needle before dialing up and giving the ordered dose. The nurses stated they did not prime the pen needles and believed priming was not required or was optional, while the DON stated priming should have been done and was standard of care. Resident #12 had a diagnosis of Type 2 DM and was ordered Insulin Aspart 18 units before meals. An LPN applied the insulin pen needle, dialed up 18 units, and administered the insulin without priming the pen needle. Resident #129 had a diagnosis of Type 2 DM and was ordered Regular Insulin per sliding scale before meals and at bedtime. An LPN applied the insulin pen needle, dialed up 4 units, and administered the insulin without priming the pen needle. Resident #144 had a diagnosis of Type 1 DM and was ordered Insulin Aspart 14 units before meals and at bedtime. An LPN applied the insulin pen needle, dialed up 14 units, and administered the insulin without priming the pen needle. The facility also failed to ensure staff properly cleaned a resident's non-invasive mechanical ventilation mask and tubing. Resident #10 had diagnoses including acute and chronic respiratory failure, COPD, and shortness of breath, and had an order to clean the non-invasive mechanical ventilation mask every morning and let it air dry. One LPN stated she cleaned the mask with a perineal wipe and had never cleaned the tubing because she had no way to clean it. Another LPN stated she cleaned the outside of the mask with an alcohol wipe and the inside with a water-soaked paper towel, then dried it with a dry paper towel, and she had never cleaned or changed the tubing. She also stated she had never received training on cleaning non-invasive mechanical ventilation masks and tubing.
Improper Cleaning of Non-Invasive Ventilation Equipment
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan for one resident who used non-invasive mechanical ventilation. The resident had diagnoses including acute and chronic respiratory failure, COPD, and shortness of breath, and her record showed orders for an AVAPS-AE ventilator at bedtime with a full face mask and for the non-invasive mechanical ventilation mask to be cleaned every morning and allowed to air dry. The care plan also identified that she had a non-invasive mechanical ventilation machine as ordered, with tubing and humidification changed per protocol. During observation and interviews, nursing staff described cleaning the resident’s mask in ways that did not match the facility policy or the physician order. One LPN stated she cleaned the mask each morning with a personal cleansing wipe and had never cleaned the tubing because she had no way to clean it. Another LPN stated she cleaned the outside of the mask with an alcohol wipe and the inside with a water-soaked paper towel, then dried it with a paper towel, and she had never cleaned or changed the AVAPS tubing. The facility policy required the tubing and mask to be cleaned daily with warm water and soap, rinsed thoroughly, and air dried. The NP stated she expected staff to follow the policy, and the DON stated cleaning the mask with a personal cleansing wipe or using alcohol wipes and water-soaked paper towels was not appropriate.
Failure to Follow EBP and Glove Precautions During Resident Care
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program by not consistently using Enhanced Barrier Precautions (EBP) and standard glove precautions during direct care. The facility policy stated that EBP includes targeted gown and glove use during high-contact resident care activities and is indicated for residents with indwelling medical devices such as central lines and urinary catheters, including during changing briefs, assisting with toileting, and device care or use. Resident #6 had a PICC line in place, but during an observation an LPN entered the room with only gloves, disconnected an antibiotic from the PICC line, and flushed the line with Heparin without wearing a gown. No EBP signage was observed on the resident’s door or in the room, and the LPN stated the resident did not require EBP. Resident #45 had a urinary catheter and a physician order for EBP. During observed catheter care and incontinence care, an LPN and a CNA wore gloves but did not wear gowns, changed the resident’s soiled brief, cleaned the perineal area, performed catheter care, and then handled a clean brief without changing gloves after contact with feces. Both staff stated gowns should have been worn and gloves should have been changed between contaminated care and handling a clean brief.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency was identified when staff failed to treat a resident with respect and dignity, as required. The resident, who had a diagnosis of unspecified dementia and moderately impaired cognition (BIMS score of 11), required substantial assistance with activities of daily living (ADLs). On the date in question, the resident reported that a CNA was rough when assisting her, prompting the resident to remove the CNA's hand and verbally express her discomfort. The resident also reported to an LPN that the CNA was consistently rude and disrespectful during care. Interviews with staff confirmed that the CNA displayed frustration and used an aggravated tone when interacting with the resident, including verbally disagreeing with her and telling her she could not walk. The LPN who entered the room observed the CNA's visible frustration and inappropriate behavior, and confirmed that such conduct was not suitable when providing care. The Director of Nursing also acknowledged that staff should not argue or disagree with residents and must always treat them with dignity and respect.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
A cognitively intact resident with a history of depressive episodes and prior sexual trauma was subjected to sexual abuse by a visitor. The visitor, who was known to the resident, showed her an explicit photo and later forced her to engage in non-consensual sexual contact in her room. The incident occurred after the visitor accompanied the resident from the patio to her room, where he shut the door and committed the act. The resident did not immediately report the abuse due to embarrassment, only disclosing the incident to staff several weeks later. Staff interviews and record reviews confirmed that the resident was not known to make false accusations and had no memory or behavioral issues documented at the time. Staff members observed the visitor and resident interacting outside and saw the visitor push the resident back to her room, but did not witness any inappropriate behavior or signs of distress. The visitor had not previously exhibited inappropriate conduct during visits, and staff were unaware of the incident until the resident reported it. The abuse resulted in actual psychological harm to the resident, who became tearful when recounting the event and reported that it triggered memories of past sexual trauma. The incident was later reported to law enforcement, leading to the arrest of the accused. The facility's records and interviews indicate that the abuse was not detected or reported by staff at the time it occurred, and the resident only received support and intervention after self-reporting the incident.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident who was frequently incontinent of bowel. On a specific date, a surveyor observed multiple spots of dried brown liquid stool on the floor between the resident's bed and the bathroom door, as well as a dried brown smear on the fitted sheet of the resident's bed. The resident reported an episode of stool incontinence two days prior, during which staff did not adequately clean the liquid stool from the floor and left the fitted sheet soiled. A CNA confirmed that she noticed the stool on the resident's floor and fitted sheet earlier that day but did not clean it. The facility's administrator stated that it was the responsibility of the nursing staff, including CNAs, to ensure a clean, homelike environment and confirmed that it was inappropriate for stool to remain on a resident's floor or sheets. The administrator expected nursing staff to clean up bodily fluids immediately when observed.
Failure to Incorporate PASRR Level II Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) Level II for a resident diagnosed with Generalized Anxiety Disorder, Schizophrenia, and Paranoid Schizophrenia. The resident was approved for a temporary nursing facility placement for 365 days, with specific recommendations including Behavioral Health Intensive Outpatient Program (IOP), Crisis Planning, and Assessment for Dementia. However, upon review, it was found that the resident's care plan did not incorporate the PASRR Level II determination and recommendations. Interviews with facility staff revealed that the responsibility for incorporating PASRR Level II recommendations into the care plan was not fulfilled. The staff members, including the care plan nurse and the social services director, acknowledged that the PASRR Level II information should have been included in the resident's care plan. The oversight was confirmed by multiple staff members, including the Minimum Data Set (MDS) coordinators and the Director of Nursing (DON), who verified that the care plan should have been updated in December 2024 when the PASRR Level II was received from the Office of Behavioral Health (OBH).
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, the facility did not provide scheduled showers for a resident who was cognitively intact and required supervision or touching assistance with showering. The resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays but did not receive a shower on a Saturday, leaving her without a shower for four days. Interviews with staff revealed that the shower aide was on vacation during the week the resident missed her shower, and it was the responsibility of the hall CNAs to provide showers in the aide's absence. However, the CNAs confirmed that they did not shower the resident and did not document any showers being given or reasons for not providing them. The Assistant Director of Nursing (ADON) confirmed the lack of documentation for the missed shower, indicating that the resident did not receive the scheduled care.
Improper Food Storage in Unit Refrigerators
Penalty
Summary
The facility failed to store food under sanitary conditions in the unit refrigerators, as observed during a tour of the facility. The inspection revealed several food items in the resident's unit refrigerator that were not properly labeled with the resident's name and date, as required by the facility's policy. Specifically, there was a brown paper bag with a wrapped breakfast sandwich, a plastic container with an unknown food, another plastic container with an unknown food, a foam cup with a pink liquid, and another plastic container with an unknown food, all lacking proper labeling. Interviews conducted with staff members confirmed the deficiency. An LPN acknowledged that staff should label all outside food items with the resident's name and date, and confirmed that the items observed were not properly labeled. The Director of Nursing was also made aware of the issue and confirmed that any food items brought in from outside the facility should be labeled with a date and the resident's name when stored in the unit refrigerator.
Inaccurate MDS Assessment for Hospice Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the hospice status of a resident. Specifically, Resident #23, who was admitted to the facility with a diagnosis of Adult Failure to Thrive, had physician orders indicating admission to hospice care effective 05/31/2024. However, the quarterly MDS assessments conducted on 07/30/2024 and 10/02/2024 incorrectly indicated that the resident was not receiving hospice care. Interviews with the MDS Coordinator (S4MDS) and the Director of Nursing (S2DON) confirmed that the MDS assessments were not coded correctly for hospice care, despite the resident's active hospice status.
Failure to Administer IV Fluids According to Standards
Penalty
Summary
The facility failed to administer intravenous (IV) fluids in accordance with professional standards of practice for a resident who required IV fluid therapy. The resident, who was admitted with diagnoses including pneumonia and dehydration, had an order for IV fluids on specific dates in February 2025. However, there were no physician orders for daily assessment, flushing, or discontinuation of the peripheral IV site. The Medication Administration Record (MAR) lacked documentation of daily assessments, flushing, or discontinuation of the IV site. Observations revealed that the resident's peripheral IV site was not visible and was covered with an undated, non-transparent, elastic ace dressing. The resident reported that the IV site hurt and had not been changed, flushed, or used since the last administration of IV fluids. Interviews with staff confirmed that the IV site was not assessed or flushed daily, and the dressing was not changed as required. The Director of Nursing acknowledged the lack of documentation and confirmed that the IV site should have been assessed, flushed daily, and changed or removed by a specific date.
Failure to Report Significant Change in Resident's Condition
Penalty
Summary
The facility failed to ensure proper communication of a significant change in a resident's condition to the physician. A Licensed Practical Nurse (LPN) identified a deformity in a resident's leg but did not report this change to the resident's physician as required by the facility's Change in Condition Policy and Procedure. The resident, who had severe cognitive impairment and multiple diagnoses including Restless Leg Syndrome and Age-Related Osteoporosis, was found to have a deformed left leg by the LPN. Despite the observation, the LPN did not notify the physician, which was a breach of the facility's policy. Interviews conducted with the nursing staff revealed that the deformity was first reported by an aide to the LPN, who assessed the resident's leg but failed to communicate the finding to the physician. The Nurse Practitioner (NP) and the Director of Nursing (DON) confirmed that the LPN did not report the deformity, and both stated that they would have expected the LPN to notify the physician. The NP noted that the resident did not express pain during the assessment, only wincing slightly, which may have contributed to the LPN's decision not to report the condition. However, the facility's policy clearly mandates prompt communication of significant changes, which was not adhered to in this case.
Failure to Implement Physician's Orders for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents, as evidenced by the lack of adherence to Physician's Orders. For Resident #6, who has a history of falling and muscle weakness, the facility did not provide a wheelchair alarm or a visual cue for wheelchair brakes, despite these being ordered by the physician. Observations and interviews confirmed that these safety measures were not in place, and staff acknowledged the oversight. Similarly, for Resident #7, who required orthopedic aftercare, the facility did not apply TED hose as ordered. Observations revealed that the TED hose were not worn by the resident and were found on top of a microwave, indicating they had not been used as prescribed. Staff interviews confirmed the failure to implement the physician's order for TED hose application.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not implementing a prescribed intervention after a fall. The resident, who had bilateral below-the-knee amputations and a history of falling, was found on the floor in her room. Following this incident, a nurse practitioner ordered a chair alarm to be placed in the resident's wheelchair as an intervention to prevent future falls. However, during observations and interviews conducted later, it was confirmed that the chair alarm was not present in the resident's wheelchair, despite the order being documented in the resident's care plan and physician orders. Interviews with staff, including a CNA, LPN, and the Assistant Director of Nursing, revealed that the resident often attempted to perform tasks without assistance, increasing the risk of falls. The staff confirmed that the chair alarm, which was intended to alert staff when the resident attempted to get up, was not implemented as required. This oversight in implementing the necessary intervention contributed to the deficiency in maintaining a safe environment for the resident.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary services to maintain personal hygiene, specifically in the context of scheduled bathing. The facility's policy required showers to be given as scheduled or as needed. However, a review of the resident's clinical record and bath log revealed that the resident, who required substantial assistance with bathing, did not receive a bath on a scheduled bath day. Interviews with staff members, including CNAs and the Assistant Director of Nursing (ADON), confirmed that the resident's scheduled bath days were Mondays, Wednesdays, and Fridays, and that the resident did not refuse baths. Despite this, there was no documentation of a bath being administered on the missed date. Interviews with the staff indicated a lack of clarity and accountability regarding who was responsible for documenting the baths. The CNAs stated that either the bath aide or the floor aides could document the baths, but there was no record of a bath being given on the missed date. The ADON and the Director of Nursing (DON) both confirmed that the resident should have received a bath on the scheduled day and that staff were expected to document the care provided. This lack of documentation and failure to provide the scheduled bath led to the deficiency noted in the report.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene and cleaning techniques during incontinence care for a resident. The facility's policy on hand hygiene, which lacked a revision date, outlined specific instances when hand hygiene should be performed, such as before and after direct resident contact, after handling soiled linens, and after removing gloves. However, during an observation, two CNAs were seen performing incontinence care on a resident without adhering to these guidelines. They failed to change gloves and perform hand hygiene after handling soiled linens and before touching clean items or the resident's belongings. The CNAs continued to use the same gloves throughout the care process, including when applying barrier cream and lotion to the resident, and when handling clean linens and the resident's personal items. Interviews with the CNAs confirmed their failure to perform hand hygiene and change gloves as required. The Director of Nursing also acknowledged that staff were trained to perform hand hygiene correctly and should have done so during the observed incontinence care.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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