Heritage Healthcare Of Hammond
Inspection history, citations, penalties and survey trends for this long-term care facility in Hammond, Louisiana.
- Location
- 1300 Derek Drive, Hammond, Louisiana 70403
- CMS Provider Number
- 195526
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage Healthcare Of Hammond during CMS and state inspections, most recent first.
A resident with stroke, vascular dementia, cognitive deficits, and documented elopement risk had physician orders and a care plan requiring a wanderguard and census checks every two hours. On the survey day, review of the MAR showed that only one census check was completed during a 12-hour shift. The resident was later observed fully dressed in bed with shoes on and without a wanderguard, which was found in the bedside drawer; the resident reported having removed it about a month earlier and expressed a desire to go home. An LPN, an NP, and the DON all confirmed the resident had an active wanderguard order and that the device was not in place and the ordered census checks were not performed as required.
After the removal of two dedicated Shower Aides, multiple residents requiring staff assistance for bathing experienced significant delays, with some waiting hours or missing scheduled baths. Residents with complex medical needs, including those with skin conditions and mobility impairments, were observed waiting in hallways and reported unmet needs. CNAs and facility leadership confirmed that increased workloads and the staffing change led to extended wait times for baths and showers.
Nursing staff failed to document the date and their initials on wound dressings after treatments for two residents with pressure ulcers, and did not use dressings large enough to fully cover and protect a wound for one resident. Observations and staff interviews confirmed that dressings were missing required documentation and, in one case, did not fully cover the wound, leaving it exposed.
A resident receiving enteral nutrition via feeding tube did not have the feeding bag labeled with the required date, time, or nurse initials, contrary to physician orders and facility policy. Both an LPN and the DON confirmed the omission during interviews, and the administrator acknowledged that staff were expected to follow labeling procedures for enteral feedings.
Nursing staff were allowed to perform wound care treatments without verified training or competency evaluation, resulting in improper documentation and inadequate wound coverage for two residents. The facility relied on self-reported experience rather than direct observation or skills assessment, and wound dressings were not consistently dated, initialed, or applied according to policy.
A resident with COPD and multiple care needs was found with an Albuterol inhaler left unattended at bedside without a required assessment or physician's order for self-administration. Facility policy mandates assessment, interdisciplinary review, and proper documentation for self-administration, none of which were completed. Staff confirmed the medication should have been secured and that administration was not properly documented on the MAR.
The facility failed to accurately document care for two residents. One resident's wound care was not recorded on a specific date, while another resident's MAR inaccurately showed oxygen therapy administration, which the resident did not receive. Interviews with staff confirmed these documentation errors.
A facility failed to provide necessary respiratory care for a resident with Congestive Heart Failure and Chronic Respiratory Failure. The resident had a physician's order for oxygen therapy at 2 liters via nasal cannula, but was observed without oxygen in use. The resident confirmed not wearing oxygen since living at the facility. Interviews with an LPN and the DON revealed that the nursing staff did not follow the physician's order.
The facility failed to conduct complete weekly skin assessments for two residents at risk of pressure ulcers. An LPN only assessed visible skin, neglecting areas under clothing, despite orders for comprehensive audits. The DON acknowledged the oversight, noting that education on full assessments was provided but not fully understood.
The facility did not ensure that all complaint surveys since the last annual survey were available for resident review. An observation revealed that the survey results folder only contained the annual recertification survey, missing the complaint survey from November 2024. The administrator confirmed the absence of these results, potentially affecting 88 residents.
A facility failed to accurately code a resident's MDS for an indwelling catheter. The resident was readmitted with a catheter, as noted in the Clinical Admission Screener, but the MDS did not reflect this. Observations confirmed the catheter's presence, and the staff responsible for MDS assessments acknowledged the error after the MDS was submitted to CMS.
A resident with a history of pulmonary embolism did not receive Eliquis as ordered due to an LPN discontinuing the medication without a physician's order. The resident was found unresponsive and later pronounced dead, with the coroner's report indicating acute myocardial infarction vs pulmonary embolism as the cause of death. The facility's failure to follow proper medication administration and documentation processes led to this significant medication error.
A resident who was cognitively intact and dependent on staff for bathing complained about not receiving a bath for five days. Despite an immediate response, the issue persisted, with the resident experiencing significant gaps between baths over two months. The ADON confirmed the complaint but admitted no measures were taken to prevent recurrence, violating the facility's grievance policy.
The facility failed to maintain an infection prevention and control program, as two LPNs did not practice proper hand hygiene during medication administration for three residents, and one LPN did not disinfect a blood glucose meter between resident use. Both LPNs and the DON confirmed these lapses in protocol.
The facility failed to ensure a resident's assessment accurately reflected their status. A resident with a diagnosis of Localized Edema, who was receiving Lasix daily, was not coded for this active diagnosis in the Quarterly MDS. This discrepancy was confirmed by staff during interviews.
A facility failed to develop a comprehensive care plan for a diabetic resident who frequently refused blood glucose monitoring. Despite multiple refusals documented over several months, no care plan was created to address this issue, as confirmed by the MDS nurse and DON.
A resident with Morbid Obesity and Chronic Diastolic Heart Failure did not receive necessary personal hygiene services as scheduled. Despite requiring substantial assistance, the resident received baths only four times over two months, leading to unkempt appearance and poor hygiene. Staff confirmed difficulties in providing showers due to lack of assistance and no accommodations were made.
The facility failed to ensure that oxygen tubing was labeled with the date for two residents who required continuous oxygen therapy. Observations and staff interviews confirmed that the tubing was not dated as per physician orders and facility protocol.
The facility failed to ensure that PRN psychotropic medications for two residents receiving Hospice care had stop dates or duration limits. Both residents had active orders for Lorazepam without a documented stop date, which was confirmed by the Hospice RN, Hospice Physician, and DON.
The facility failed to post daily nurse staffing data, including the resident census, in two observed areas. Observations and interviews confirmed the omission, with the ADON admitting she was unaware of the requirement.
Failure to Ensure Wanderguard Use and Required Census Checks for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and follow physician orders for an elopement-risk resident. The resident was admitted with stroke, vascular dementia with behavioral disturbance, cognitive communication deficit, and Wernicke’s encephalopathy, and had a BIMS score of 8 indicating moderate cognitive impairment. The resident’s elopement risk evaluation documented that he was an elopement risk due to expressing a desire to go home, packing belongings, or staying near exit doors, and he had an active order to continue using a wanderguard. The care plan identified him as an elopement risk/wanderer who made statements about leaving, required a wanderguard, and needed cueing, reorientation, and supervision due to impaired cognitive status. Physician orders and the MAR specified wanderguard census checks every two hours. On the day of the survey, review of the MAR showed that the ordered every-two-hour census checks were not completed for the 7:00 a.m. to 7:00 p.m. shift, with only one census check documented at 10:48 a.m. When observed at 2:07 p.m., the resident was fully dressed in bed, wearing shoes, without a wanderguard in place, and he stated he had removed the wanderguard about a month earlier and expressed a need to go home to mow the grass and grate his driveway. The wanderguard was found in the top drawer of his bedside table. The NP and DON both confirmed the resident had an order for a wanderguard due to elopement risk and that it was not in place as it should have been. The LPN assigned to the resident confirmed she was unaware the wanderguard was not on the resident, acknowledged she had only performed one census check during her shift, and confirmed she did not complete the ordered every-two-hour census checks.
Insufficient Staffing Leads to Delays in Resident Bathing
Penalty
Summary
The facility failed to provide sufficient numbers of direct care staff to ensure timely assistance with baths and showers for all residents, as evidenced by observations, interviews, and record reviews. The facility had a policy requiring showers to be given as scheduled and/or as needed, and residents were not to be left alone in the shower room. However, after the removal of two dedicated Shower Aides from daily assignments, residents experienced significant delays in receiving their scheduled baths and showers, with some waiting in excess of two to three hours. Multiple residents were observed waiting in wheelchairs outside the bath/shower room for extended periods, and several reported missing activities or having to clean themselves due to the lack of available staff. Residents affected included individuals with complex medical needs, such as one with chronic skin conditions requiring daily bathing to prevent infection and control odor, and others with severe morbid obesity, congestive heart failure, and mobility impairments. These residents were assessed as requiring varying levels of staff assistance for activities of daily living, including bathing. Despite their care plans indicating the need for staff support, residents consistently reported long wait times and unmet needs following the staffing change. Resident council meeting minutes and direct interviews confirmed that the new process was not working, and residents' preferences and schedules for bathing were not being honored. Staff interviews corroborated the residents' accounts, with CNAs reporting increased workloads after being reassigned from dedicated shower duties to broader floor responsibilities. CNAs described being responsible for large numbers of residents, many of whom required two-person assistance, frequent turning, repositioning, and incontinence care, making it difficult or impossible to provide timely baths and showers. Facility leadership acknowledged the recent system change and the resulting delays, stating that the facility was still working out issues with the new staffing model, but confirmed that residents' needs were not being met in a timely manner.
Failure to Document and Properly Apply Pressure Ulcer Dressings
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards and its own wound care policy for two of four residents reviewed. Specifically, nursing staff did not document the date and their initials on wound dressings after performing treatments, as required by facility policy. Observations revealed that dressings on multiple wound sites, including the sacrum, bilateral heels, and right ischium, lacked this essential documentation. Interviews with the wound treatment nurse and a CNA confirmed that the dressings were missing the date and initials, and the nurse was unaware of who performed the treatments on certain days. The absence of this information was acknowledged as important for tracking when treatments were performed and for monitoring wound drainage over time. Additionally, the facility failed to ensure that wound dressings were large enough to fully cover and protect the wounds for one resident. An observation showed that a sacral wound dressing did not extend past the edges of the wound, leaving a significant portion of the wound exposed to air and potential contaminants. Both the wound treatment nurse and nurse practitioner confirmed that dressings should fully cover wounds as ordered, and that the observed practice did not meet this standard. The Director of Nursing and facility administrator also confirmed that dressings should completely cover wounds and include the date and initials of the person performing the treatment.
Failure to Label Enteral Feeding Bag per Policy and Physician Orders
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was provided with appropriate treatment and services to prevent complications. Specifically, the enteral feeding bag in use for a resident with a gastrostomy was not labeled with the required date, time, or nurse initials, as observed during a survey. This omission was in direct violation of both physician orders and the facility's own policy, which require that the formula container, syringe, and administration set be labeled with the resident's name, date, time, and nurse's initials at the start of infusion. Record review showed that the resident was receiving continuous enteral nutrition due to dysphagia, with orders specifying the use of a closed system container and the need to change and label the feeding administration set with each new bottle. During interviews, both the LPN and the Director of Nursing confirmed that the labeling had not been completed as required. The facility administrator also acknowledged that staff were expected to follow physician orders and facility policy regarding enteral feedings, but this was not done in this instance.
Failure to Ensure Nursing Staff Competency in Wound Care Treatments
Penalty
Summary
The facility failed to implement a measurable evaluation system to ensure that nursing staff were properly trained and competent to perform wound treatments as ordered before being allowed to do so independently. Observations revealed that wound dressings for two residents did not have the required date and initials of the nurse who performed the treatment, as specified in the facility's wound care policy. Additionally, one resident's wound dressing was not large enough to fully cover and protect the wound, leaving a portion exposed to air and potential contaminants. Interviews with staff indicated that the facility assigned various nurses, including those not regularly performing wound care, to conduct wound treatments on weekends. One LPN, who was assigned to perform wound treatments, confirmed she had not received recent training or competency evaluation for wound care and was unaware of the requirement to date and initial dressings. The staff development nurse responsible for training and competency evaluations admitted she did not provide actual training or observe wound care skills, instead relying on self-reported experience from the nurses. She also acknowledged she was not competent in wound care herself and could not evaluate others in this skill. Further interviews with the DON and administrator confirmed that wound care is considered a specialized skill requiring specific training and competency evaluation, which was not being conducted. The staff development nurse's initials on competency forms only indicated that she asked nurses if they had performed the skill before, not that she had observed or evaluated their competency. This lack of a structured training and competency evaluation system resulted in nurses performing wound care without verified skills, leading to improper documentation and inadequate wound coverage for residents.
Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
The facility failed to ensure the safe disposition and administration of medications for a resident, as evidenced by the presence of an Albuterol Sulfate Inhaler left unattended at the bedside of a resident with chronic obstructive pulmonary disease (COPD), cognitive communication deficit, lack of coordination, weakness, and a disorder of the brain. The resident was assessed as cognitively intact but required varying levels of assistance with daily activities, including substantial or maximal assistance with toileting, bathing, and dressing. Despite these needs, there was no documented assessment for the resident's ability to self-administer medications, nor was there a physician's order permitting self-administration or allowing the inhaler to be kept at bedside. Review of the facility's policy indicated that residents must be assessed for self-administration of medication upon admission, quarterly, annually, with significant changes, or as needed. The policy also required an interdisciplinary team review, a physician's order, and care plan updates if self-administration was approved. In this case, the resident's clinical record, care plan, and medication administration record (MAR) showed no evidence of such an assessment, order, or care plan update. The MAR also lacked documentation of the inhaler being administered during the review period, despite the resident's need for frequent use of the inhaler for shortness of breath. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed that the resident had not been assessed for self-administration, did not have a physician's order for self-administration or for the inhaler to be kept at bedside, and that the medication should have been secured in the medication cart when not in use. Staff also confirmed that, even if self-administration were permitted, the date and time of administration should be documented on the MAR, which was not done in this case.
Documentation Errors in Wound Care and Oxygen Use
Penalty
Summary
The facility failed to maintain accurate documentation for two residents, leading to deficiencies in care. For one resident, the Treatment Administration Record (TAR) for January 2025 was found to be incomplete, as it lacked documentation of daily wound care for a surgical incision on January 1, 2025. Interviews with the LPN and the Director of Nursing confirmed that the documentation was missing and should have been completed, indicating a lapse in maintaining accurate medical records. For another resident, the Medication Administration Record (MAR) for February 2025 inaccurately documented the administration of oxygen therapy. Despite the MAR indicating that the resident received oxygen on multiple dates, an observation and interview with the resident revealed that he did not use oxygen at all during his stay. The LPN responsible for the documentation confirmed the error, acknowledging that the resident did not receive the treatment as recorded. This discrepancy highlights a failure in ensuring accurate documentation of treatments provided to residents.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, as observed during a survey. Resident #3, who was admitted with diagnoses including Congestive Heart Failure and Chronic Respiratory Failure, had a physician's order for oxygen therapy at 2 liters via nasal cannula. However, during an observation, Resident #3 was found resting in bed without oxygen in use. The resident confirmed that he had not been wearing oxygen since living at the facility. Interviews with the LPN and the Director of Nursing revealed that the nursing staff did not follow the physician's order to administer the prescribed oxygen therapy to Resident #3.
Inadequate Skin Assessments for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate weekly skin assessments for two residents, both of whom were at risk for pressure ulcers. Resident #2 was admitted with a physician order for a weekly body audit starting on 12/31/2024, and Resident #3 had a similar order starting on 01/24/2025. However, the Licensed Practical Nurse (LPN) responsible for these assessments, S3LPN, admitted to only assessing the skin visible to her eyes and not under any clothing, relying on CNAs or shower aides to report any skin breakdown in areas covered by clothing. The Director of Nursing (DON), S2DON, confirmed that the responsibility for weekly skin audits lay with the LPN caring for the resident. Although education was provided upon hire on how to conduct complete skin audits, including checking less visible areas such as cracks, crevices, and behind the ears, it was not clear to some nurses that they should also assess the larger areas of skin under clothing. This oversight in the skin assessment process led to the deficiency identified by the surveyors.
Facility Failed to Provide Access to Complaint Survey Results
Penalty
Summary
The facility failed to ensure that all complaint surveys since the last annual survey were available for resident review. During an observation, it was noted that the facility's folder containing survey results, located on the bulletin board, only included the annual recertification survey dated June 7, 2024. There was no documented evidence of the complaint survey results from November 13, 2024, being available for review. This was confirmed during an interview with the facility's administrator, who acknowledged that the complaint survey results were missing from the folder. This deficiency had the potential to affect the 88 residents currently residing in the facility.
Inaccurate MDS Coding for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) accurately reflected the resident's status, specifically regarding the presence of an indwelling catheter. Resident #2 was admitted to the facility and later readmitted from a local hospital with an indwelling catheter, as documented in the Clinical Admission Screener. However, the Significant Change MDS with an Assessment Reference Date of 11/01/2024 did not code for the indwelling catheter, despite observations on 11/12/2024 and 11/13/2024 confirming the presence of the catheter. During an interview, the staff member responsible for completing MDS assessments acknowledged the error and confirmed that the MDS had been submitted to CMS without accurate coding.
Failure to Administer Eliquis as Ordered
Penalty
Summary
The facility failed to ensure that a resident received Eliquis as ordered by the physician, resulting in a significant medication error. The resident, who had a history of pulmonary embolism and acute embolism and thrombus of the lower extremity, was admitted with orders to take Eliquis 5 mg twice daily. However, the medication was discontinued by an LPN without a physician's order, and the resident did not receive Eliquis from the date of discontinuation until their death. The resident was found unresponsive, pulseless, and not breathing, and the coroner's report indicated the cause of death as acute myocardial infarction vs pulmonary embolism, hypertension, and changes of aging. The LPN who discontinued the Eliquis order did so without proper documentation or a physician's directive, believing the resident had an upcoming procedure. The Director of Nursing confirmed that there was no documentation or order to discontinue the medication, and the medication was removed from the Medication Administration Record (MAR) without proper authorization. The facility's process for verifying medication orders was not followed, leading to the resident not receiving the necessary anticoagulant medication. Interviews with the nursing staff revealed that the facility had recently implemented a new computer system, which may have contributed to the error. The Data Entry nurse and other staff were responsible for ensuring the accuracy of medication orders, but the error was not identified until after the resident's death. The facility's failure to administer Eliquis as ordered and the lack of proper documentation and verification processes directly contributed to the resident's death.
Failure to Resolve Resident Grievances Regarding Bathing
Penalty
Summary
The facility failed to initiate and resolve grievances voiced by a resident who was cognitively intact and dependent on staff for bathing. The resident had complained about not receiving a bath for five days, and although a bath was given immediately after the complaint, the issue persisted. The resident's care records showed infrequent bathing, with significant gaps between baths over two months. Despite the resident's complaint in April, the facility did not implement measures to prevent recurrence, leading to the resident appearing unkempt and reporting another instance of not being bathed for seven days in June. During an interview, the Assistant Director of Nursing (ADON) confirmed that the resident had complained about not being bathed and that she had personally bathed the resident. However, the ADON admitted that no measures were put in place to prevent the issue from happening again. This lack of follow-up and resolution is a clear violation of the facility's grievance policy, which mandates a resolution within five business days of the grievance being filed.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by improper hand hygiene practices and inadequate disinfection of medical equipment. Specifically, two LPNs did not sanitize their hands before and after administering medications to three residents. One LPN was observed administering medication to a resident without performing hand hygiene before or after the process. Another LPN also failed to sanitize her hands before preparing and administering medications to two residents consecutively. Both LPNs acknowledged their failure to follow the facility's hand hygiene policy during interviews. Additionally, the facility did not ensure proper disinfection of blood glucose meters between resident use. An LPN was observed performing a blood glucose check on a resident and then placing the glucometer back in the medication cart without sanitizing it. The LPN confirmed that she did not clean the glucometer after use, which is against the facility's policy. The Director of Nursing also confirmed that the glucometer should be cleaned before and after each resident use and that hand hygiene should be performed before and after administering medications to each resident.
Failure to Accurately Reflect Resident's Status in MDS
Penalty
Summary
The facility failed to ensure a resident's assessment accurately reflected the resident's status. Resident #10, who was admitted with a diagnosis of Localized Edema, had been receiving Lasix 40 mg daily as prescribed. However, the Quarterly MDS with an ARD of 05/15/2024 did not code Localized Edema as an active diagnosis in Section I. This discrepancy was confirmed by S10MDS and S2DON during interviews, who acknowledged that the MDS should have included the diagnosis since the resident was actively receiving medication for it.
Failure to Develop Care Plan for Diabetic Resident Refusing Blood Glucose Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with diabetes who frequently refused blood glucose monitoring. The resident, who had diagnoses including Type 2 Diabetes Mellitus with unspecified complications and diabetic neuropathy, had multiple instances where Accu Checks were not administered due to refusal. Despite these frequent refusals, no care plan was developed to address this issue, as confirmed by the review of the resident's clinical records and MAR for March, April, and May 2024. The facility's policy requires that care plans be revised to reflect changes in the resident's behavior and care needs, but this was not done for the resident in question. Interviews with the MDS nurse and the DON revealed that the resident's frequent refusals of Accu Checks were discussed in daily morning meetings. However, the MDS nurse, who was responsible for updating care plans, did not recall these discussions and was not aware of the frequent refusals. Consequently, no care plan was developed to address the resident's refusals, which was a clear oversight in adhering to the facility's policy. Both the MDS nurse and the DON confirmed that a care plan should have been developed for the resident's frequent refusals of Accu Checks.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that Resident #17 received the necessary services to maintain personal hygiene. The resident, who was admitted with diagnoses including Morbid Obesity and Chronic Diastolic Heart Failure, required substantial assistance with bathing. Despite the facility's policy that baths and showers should be given as scheduled and as needed, records showed that Resident #17 received baths only four times over a two-month period. Observations and interviews revealed that the resident was unkempt, with oily hair, dandruff, and flaky skin, and had not received a bath or hair wash for seven days. The resident confirmed that her scheduled bath days were Mondays, Wednesdays, and Fridays, and expressed a preference for showers or whirlpool baths over bed baths. However, she often did not receive these due to staffing issues and difficulty getting her into a shower chair without assistance. Interviews with staff members, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), confirmed that Resident #17 had difficulty getting into the shower chair and required assistance, which was often unavailable. The CNA admitted to giving the resident bed baths instead of showers due to these challenges but also acknowledged that there were times when the resident did not receive any form of bath before the end of her shift. The ADON confirmed that no accommodations were made to ensure the resident received her scheduled baths, leading to the observed deficiency in personal hygiene care.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. Specifically, the facility did not ensure that oxygen tubing was labeled with the date for two residents who required continuous oxygen therapy. Resident #5, who was admitted with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea, had physician orders to change and label oxygen tubing weekly. However, multiple observations revealed that the oxygen tubing in use was not dated. Interviews with the resident and staff confirmed that the tubing should have been dated but was not. Similarly, Resident #17, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia, also had physician orders to change and label oxygen tubing weekly. Observations of Resident #17 revealed that the oxygen tubing in use was not dated. Staff interviews confirmed that the tubing should have been dated according to the facility's protocol. The Assistant Director of Nursing also confirmed that the protocol for oxygen tubing changes was not followed as required.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for two residents. Resident #4, who was admitted with diagnoses including Dementia, Anxiety Disorder, Major Depressive Disorder, and Alzheimer's Disease, had active physician orders for Ativan and Lorazepam without a documented stop date. Similarly, Resident #7, admitted with diagnoses such as Senile Degeneration of Brain, Unspecified Dementia, Bipolar Disorders, and Major Depressive Disorder, had a PRN order for Lorazepam without a stop date. Both residents were receiving Hospice services, and the orders for psychotropic medications did not comply with the requirement to have a stop date or duration limit of 14 days for PRN use. Interviews with the Hospice Registered Nurse, Hospice Physician, and the Director of Nursing (S2DON) confirmed that the PRN orders for Lorazepam for residents receiving Hospice care did not include a stop date or duration. The Hospice Physician was unaware of the requirement for a stop date, and the Director of Nursing confirmed that the facility did not require stop dates for PRN Lorazepam orders for Hospice residents. This oversight led to the deficiency in ensuring that residents' drug regimens were free from unnecessary psychotropic medications.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data on a daily basis, including the total resident census number, in two observed areas. On 06/04/2024, observations at 9:46 a.m. and 9:50 a.m. revealed that the Daily Nursing Assignment sheets posted at Nursing Station A and the bulletin board at the end of Hall B did not include the resident census. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that the resident census number was missing from the posted sheets. The ADON, responsible for posting the sheets, admitted she was unaware that the resident census needed to be included.
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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