Hilltop Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pineville, Louisiana.
- Location
- 336 Edgewood Drive, Pineville, Louisiana 71360
- CMS Provider Number
- 195390
- Inspections on file
- 22
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 16 (2 serious)
Citation history
Health deficiencies cited at Hilltop Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Address Significant Weight Loss: A resident with stroke-related deficits, vitamin deficiency, and muscle wasting had repeated significant weight loss while on weekly weights and identified as high risk for malnutrition. The chart showed no documented dietary interventions despite the loss, and the DON confirmed the resident’s weight loss was significant but not addressed before hospitalization; the RD stated she was not notified until after she first saw the resident and then made new recommendations.
Missing Beard Restraint During Puree Meal Preparation: A dietary staff member with a full beard/goatee was observed preparing puree meals for 9 residents while wearing a hair net but no beard restraint. The Dietary Manager later confirmed the beard restraint was missing and should have been worn during meal prep.
Inadequate Supply of Clean Towels and Washcloths: Residents reported not having enough towels or washcloths available in hall linen storage for personal hygiene. Observations found multiple halls with few or none of these items, and CNAs said this had been an ongoing issue, requiring them to search the facility for supplies needed for peri- and ADL care. An Assistant Admin confirmed the shortage affected all residents.
A facility failed to ensure residents received mail on Saturdays, despite resident rights stating mail should be promptly received unopened. During a Resident Council meeting, residents said weekend mail was not delivered until Monday, and the SSD confirmed weekend mail was held until Monday for sorting. The Weekend Activity Director stated she had never been trained or instructed to handle resident mail on Saturdays and confirmed mail had not been delivered on Saturdays since her hire.
A resident at high risk for malnutrition had weekly weights showing significant weight loss, but the DON did not notify the MD or RD as required by the care plan. The resident had diagnoses including CVA-related hemiplegia, vitamin deficiency, and muscle wasting, required set-up assistance with eating, and the RD stated she was not informed of the weight loss until later, when new recommendations were made.
Failure to reposition a resident as ordered. A resident with Parkinson's disease, moderate cognitive impairment, and multiple other diagnoses had a care plan for turning and repositioning every 2 hours and as needed while in bed or chair. Observations showed CNAs entered the room to reposition the resident, but the resident was later found not to have been repositioned every 2 hours and remained on his back side. A CNA acknowledged the missed repositioning, and the DON confirmed the resident should have been turned and repositioned but was not.
A resident identified as an unsafe smoker was observed smoking without staff supervision despite physician orders, a smoking safety assessment, and the care plan requiring 1 cigarette at a time with staff supervision in designated smoking areas. Staff wheeled the resident to the smoking area, lit the cigarette, and walked away, and later observations again showed the resident smoking unsupervised; the Charge RN and DON confirmed the resident should have been supervised.
Pureed Diets Not Followed for Multiple Residents: Three residents with physician-ordered pureed diets were observed receiving breakfast trays that included ground sausage or ground meat instead of pureed food. Meal tickets reflected the pureed orders, and the dietary manager confirmed that one resident ordered pureed received ground meat and acknowledged the same issue for the other two residents.
Improper Storage of Clean Linens and Equipment: Staff were observed drying and storing lift slings, a privacy curtain, and a geri-chair cushion on a metal rack outside the laundry room, piled together and exposed to outside air and elements. A privacy curtain was seen touching the concrete with debris on it, and the LNA/Laundry staff and Laundry Supervisor confirmed the items should have been clean but were not.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
The facility did not post up-to-date nurse staffing information, as the displayed staffing sheet was outdated and did not reflect current staffing. The DON and an RN/Charge Nurse confirmed that the staff member responsible for posting this information had quit abruptly, leading to the deficiency.
The facility failed to provide quarterly personal funds statements to three residents, despite holding funds for 52 residents. The residents had authorized the facility to manage their funds and elected to receive statements, but interviews confirmed they never received them. Staff admitted there was no system in place to ensure the distribution of these statements.
The facility did not hold quarterly Quality Assessment and Assurance (QAA) meetings as required, with the last meeting occurring several months ago. The Director of Nursing confirmed that no meetings had been conducted since, and the Medical Director had not reviewed current QAPI data.
A resident was found self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan. The facility's policy requires an interdisciplinary team assessment and specific order for self-administration, which were not in place. Staff confirmed the absence of necessary documentation and approval for the resident's self-administration of the nasal spray.
A facility failed to ensure a resident's call light was accessible, as required by policy. The resident, with severe cognitive impairment and significant physical assistance needs, had their call light positioned out of reach at the foot of the bed. Observations confirmed the call light was not visible or accessible, and staff acknowledged it should have been within reach.
The facility failed to report serious injuries of three residents to the State Survey Agency within the required timeframe. A resident with severe cognitive impairment sustained an avulsion fracture, another had an un-witnessed fall resulting in a femur fracture, and a third resident was found to have a compression fracture. Despite being aware of these injuries, the facility did not report them as mandated by state law.
A facility failed to complete required discharge documentation for a resident with multiple diagnoses, including anxiety disorders and diabetes. The resident's medical record lacked a discharge summary, physician order, and necessary information for the receiving provider. Interviews confirmed the absence of documentation, despite the Administrator's involvement in the transfer.
A resident with severe cognitive impairment and a right hand contracture did not have a required hand roll in place, as observed over several days. Despite care plan and physician orders specifying the use of a hand roll, staff were unable to locate it, indicating a failure to implement the resident's care plan.
The facility failed to update care plans for two residents, one requiring oxygen therapy and another self-administering medications. A resident adjusted her oxygen concentrator against physician orders, and another resident self-administered nasal spray without a care plan or order. Staff confirmed the care plans were not updated to reflect these needs.
The facility failed to document discharge summaries for two residents, one with multiple diagnoses including Alzheimer's and another with moderate cognitive impairment. Both residents were discharged without the necessary documentation, as confirmed by interviews with facility staff.
The facility did not complete annual performance reviews for two CNAs as required by policy. The DON, responsible for conducting and signing off on these evaluations, confirmed that they had not been completed. Personnel records lacked evidence of evaluations for CNAs hired over a year ago.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status by not providing dietary interventions for significant weight loss. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, deficiency of other vitamins, and muscle wasting. The resident’s orders included weekly weights and identified the resident as high risk of malnutrition related to GERD, hyperlipidemia, hypertension, anxiety, pain, and hypothyroidism. The admission MDS showed a BIMS score of 14 and that the resident required set-up assistance with eating. The resident’s weight record showed repeated significant losses, including a drop from 108.0 lbs to 100.0 lbs and other measurements reflecting a 5% or greater loss over 30 days. The significant change MDS documented weight loss of 5% or more in the last month and that the resident was not on a prescribed weight loss regimen. The care plan identified the resident as high risk for malnutrition and dehydration and included weekly weights and reporting significant weight loss to the MD/NP, but the record contained no evidence of dietary interventions to address the weight loss. The DON stated she was responsible for entering weights and said she would notify the physician and RD when a weight loss triggered, but confirmed there was no documentation of dietary interventions before the resident’s hospitalization. The RD stated she had not been notified of the significant weight loss and first saw the resident after the hospitalization, when new recommendations were made.
Missing Beard Restraint During Puree Meal Preparation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. During observation on 02/09/2026 at 11:15 a.m., S13 was seen wearing a hair net but no beard restraint while preparing the puree recipe for all 9 residents who received a puree diet. S13 stated that he always prepared the puree meals for the residents in the facility. During an interview later that day at 12:45 p.m., the Dietary Manager confirmed that S13 did not have a beard restraint net to cover his beard during puree meal preparation and should have.
Inadequate Supply of Clean Towels and Washcloths
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by not maintaining an adequate supply of clean towels and washcloths in the hall linen storage areas. During the Resident Council Meeting, two residents expressed concerns about not having enough towels or washcloths available to properly clean and dry themselves. Observation of the linen closets showed that Hall X had six towels and no washcloths, Hall V had no towels and four washcloths, Hall W had one towel and four washcloths, and later Hall V had no towels or washcloths, Hall W had no towels and one washcloth, Hall X had six towels and one washcloth, and Hall Z had no towels or washcloths. Interviews with laundry staff revealed that linens, towels, and washcloths were delivered to the halls in the morning and picked up during the evening shift, but after 11:00 p.m. there was no laundry service until morning workers arrived. CNAs reported that the lack of towels and washcloths had been an ongoing issue and that they had to search the facility to find them. One CNA stated that there were no towels or washcloths available upon arrival for resident care, and laundry staff confirmed that towels and washcloths were used for peri- and ADL care. An Assistant Admin confirmed there was an inadequate number of towels and washcloths for all residents in the facility.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, despite the resident rights admission packet stating that residents have the right to send and promptly receive unopened mail. During the Resident Council meeting, residents stated they did not receive mail on Saturdays and wanted personal mail delivered the same day it arrived at the facility. The S5 SSD stated that weekend mail was not given to residents on Saturdays and was instead received on Monday mornings for sorting and distribution. In an interview, the S2 Assistant Admin stated the Weekend Activity Director should distribute resident mail on Saturdays when it is received and not wait until Monday morning. The S6 Weekend SSD stated she had worked as the Weekend Activity Director since 03/2024 and had never been trained or instructed to procure, sort, or deliver mail to residents on Saturdays, and confirmed that no mail had been delivered to residents on Saturday since her hiring.
Failure to Notify Physician and RD of Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident identified as high risk for malnutrition. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, deficiency of other vitamins, and muscle wasting. The resident’s admission MDS showed a BIMS score of 14, indicating intact cognition, and the resident required set-up assistance with eating. The physician orders included weekly weights and identified the resident as high risk of malnutrition related to GERD, hyperlipidemia, hypertension, anxiety, pain, and hypothyroidism. The resident’s weekly weights showed a decline from 108.0 pounds to 101.8 pounds, with documentation reflecting significant weight loss of 5% or more over 30 days and 7.5% over a comparison period. The care plan addressed high risk for malnutrition and dehydration and included weekly weights and reporting significant weight loss to the MD/NP, but the DON stated the physician and RD were not notified of the significant weight loss. The DON confirmed that if it was not charted, the physician or RD was not notified, and the RD stated she was not notified of the weight loss and first saw the resident later, when she made new recommendations.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out ADLs received the ordered services to maintain bed mobility. Resident #5 had diagnoses including Parkinson's disease without dyskinesia, persistent atrial fibrillation, bipolar disorder, generalized anxiety disorder, depressive disorder, alcohol abuse, and hypotension. The resident's quarterly MDS showed a BIMS of 9, indicating moderate cognition, and the care plan included an intervention for turning and repositioning every 2 hours and as needed while in bed or chair. The facility policy also stated that residents unable to move in bed without assistance should be changed at least every 2 hours. An observation showed an over-bed sign in Resident #5's room directing repositioning at specific intervals and positions. During an observation, two CNAs entered the room to reposition the resident, then exited. Later observation showed the resident was not repositioned every 2 hours and remained on his back side during the observed period. One CNA stated the resident required repositioning every 2 hours and acknowledged she did not reposition him every 2 hours but should have. The DON confirmed staff were to reposition residents every 2 hours and confirmed Resident #5 should have been turned and repositioned but was not.
Unsafe Smoker Left Unsupervised While Smoking
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents when smoking. Resident #34 was admitted to the facility on 06/06/2011 and had diagnoses including Primary Generalized Osteoarthritis, Lack of Coordination, Anxiety Disorder, and Drug Induced Subacute Dyskinesia. Her quarterly MDS with an ARD of 01/09/2026 showed a BIMS score of 12 and that she was a current tobacco user. Her physician orders for 02/2026 stated that she was an unsafe smoker and was to receive only 1 cigarette at a time at designated smoke times in designated areas with staff supervision. The smoking safety assessment and care plan also identified Resident #34 as an unsafe smoker and directed that she receive 1 cigarette at a time with staff supervision. Despite this, observation on 02/09/2026 showed a staff member wheeling her to the designated smoking area, giving her one cigarette, lighting it, and walking away while she smoked unsupervised. Additional observations on 02/09/2026 and 02/10/2026 showed her sitting in the designated smoking area smoking without supervision. The Charge RN stated that she was an unsafe smoker, and the DON confirmed that she should have been supervised while smoking but was not.
Pureed Diets Not Followed for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents received mechanically altered diets as ordered by the physician for 3 reviewed residents (#4, #49, and #50). Resident #4 had diagnoses including generalized anxiety disorder, essential hypertension, chronic embolism and thrombosis of other specified veins, and localized edema, and his record showed an order for a regular NSOT diet with pureed texture and regular/thin liquids. During breakfast observation, Resident #4 was served scrambled eggs and ground sausage, which were not pureed as ordered, and the meal ticket also reflected a pureed diet. Resident #49 had diagnoses including atherosclerotic heart disease, hypertension, congestive heart failure, and severe protein calorie malnutrition, and was ordered a regular diet with pureed texture and regular/thin liquids. On two separate breakfast observations, Resident #49’s meal ticket showed a pureed diet, but the tray contained sausage that was ground in texture rather than pureed. Resident #50 had diagnoses including diffuse traumatic brain injury, nutritional deficiencies, hypertension, COPD, dysphagia following other cerebrovascular disease, and cognitive communication disorder, and was ordered a regular diet with pureed texture and nectar/mildly thick liquids. During breakfast observation, Resident #50’s tray also contained sausage that was ground in texture rather than pureed as ordered. The dietary manager confirmed that Resident #49 was ordered a pureed diet but received ground meat, and acknowledged that Residents #4 and #50, who were ordered pureed diets, also received ground meat.
Improper Storage of Clean Linens and Equipment
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Observations on 02/10/2026 and 02/11/2026 showed lift slings and a privacy curtain draped on a metal rack outside the laundry room door, piled on top of each other and left open to outside air and elements. During an interview, S9 Laundry stated this was how lift slings and privacy curtains were dried and stored because the laundry had nowhere else to dry or store large items. On 02/11/2026, another observation of the same area showed a metal hanging rack with 6 lift slings, 1 privacy curtain, and a geri-chair cushion piled on top of each other and draped over the rack. The privacy curtain was hanging down and touching the concrete, with debris on it. S9 Laundry confirmed the curtain should not have been touching the concrete. S16 Laundry Supervisor also confirmed the findings, stating CNAs remove the slings from the lifts at night, take them to the laundry to be washed, and hang them on the metal rack to dry until CNAs pick them up in the morning. S16 Laundry Supervisor removed the curtain and observed debris and rust marks where it had contacted the metal rack, and confirmed the lift slings, privacy curtain, and geri-chair pad should have been clean but were not.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing pattern was posted as required. On observation, the posted staffing information was found to be outdated, displaying a date from nearly two weeks prior. During interviews, the Director of Nursing (DON) and an RN/Charge Nurse confirmed that the staff member responsible for posting the daily staffing pattern had quit abruptly, resulting in the failure to update and post current staffing information. The posted sheet did not reflect the current date or actual staffing for the day of the survey, despite a facility census of 89 residents.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements to three residents, despite holding personal funds for a total of 52 residents. The facility's policy, as outlined in the Admission Packet dated February 2023, mandates that individual financial records must be available through quarterly statements and upon request to the resident or their legal representative. However, interviews and record reviews revealed that Residents #44, #67, and #75, who had authorized the facility to manage their funds and elected to receive quarterly statements, did not receive them. Interviews with the residents confirmed that they had never received the required quarterly statements and expressed a desire to receive them. Further interviews with facility staff, including S9 HR and S14 BOM, confirmed the absence of a system to ensure the distribution of these statements. The staff acknowledged that no quarterly statements were provided to any of the 52 residents whose funds were managed by the facility, indicating a systemic issue in the facility's financial management practices.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly and included the required staff members. The facility's policy on Quality Assurance and Performance Improvement (QAPI) guidelines mandates that the committee should identify issues affecting the quality of care and services provided to residents, with the Medical Director and consultants included in quarterly meetings. However, a review of the facility's QAA committee sign-in sheets revealed that the last meeting was conducted on July 11, 2023. An interview with the Director of Nursing (DON) confirmed that no quarterly QAA meetings had been conducted since that date, and neither the Medical Director nor any governing body member had reviewed current QAPI data since the last meeting.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication. Specifically, Resident #75 was found to be self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan in place. The facility's policy requires that the interdisciplinary team assess a resident's ability to safely self-administer medications and obtain a specific order if the right is granted. However, Resident #75's clinical record lacked a self-administration assessment for the Afrin nasal spray, and there was no care plan reflecting self-administration. Observations and interviews revealed that Resident #75 had Afrin nasal spray and eye drops at his bedside, which he was self-administering. Interviews with facility staff, including LPNs and RNs, confirmed that there was no self-administration assessment or physician's order for the Afrin nasal spray. The Director of Nursing and another RN also confirmed the absence of a care plan or order for self-administration, acknowledging that the nasal spray should not have been in the resident's room without proper documentation and approval.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for a resident by not providing an accessible call light. The facility's policy requires that each resident have the call light within reach at all times, regardless of their ability to use it. However, observations revealed that the call light for a resident with severe cognitive impairment and significant physical assistance needs was not within reach. The resident, who required extensive assistance with bed mobility and was totally dependent on staff for transfers, had their call light positioned at the foot of the bed, out of reach. Further observations confirmed that the call light was not visible or accessible to the resident, as it was found behind the bed near the foot. Staff members, including an LPN and a CNA, confirmed during an interview that the call light was not within reach and acknowledged that it should have been. The resident's care plan specifically noted the need to keep the call light in reach and respond in a timely manner, highlighting the facility's failure to adhere to its own policies and the resident's care plan requirements.
Failure to Report Resident Injuries Timely
Penalty
Summary
The facility failed to report serious bodily injuries of three residents to the State Survey Agency within the required two-hour timeframe, as mandated by state law. Resident #42, who had severe cognitive impairment and required extensive assistance, sustained an avulsion fracture of the medial femoral condyle. The injury was discovered following an x-ray ordered by a nurse practitioner to rule out osteomyelitis. Despite the facility's awareness of the injury on the day it was discovered, the incident was not reported to the State Survey Agency as required. Resident #93, also with severe cognitive impairment, experienced an un-witnessed fall resulting in a right femur neck fracture with impaction. Initially, x-rays did not reveal any fractures, but subsequent imaging confirmed the injury. The facility was aware of the fracture on the day it was confirmed, yet failed to report it to the State Survey Agency. The resident's fall and subsequent injury were not witnessed, and the resident was known to be at high risk for falls. Resident #96, with moderate cognitive impairment, was found to have a compression fracture of L1 following an MRI. The facility became aware of this major injury of unknown origin on the day the MRI results were received. However, the required report to the State Survey Agency was not initiated. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed for any of the three residents, resulting in a deficiency.
Failure to Complete Required Discharge Documentation
Penalty
Summary
The facility failed to ensure that required discharge documentation was completed for a resident who was reviewed for discharge. The facility's policy on discharge planning emphasizes the importance of a planned program of continuing care to meet each resident's discharge needs. However, the facility did not adhere to its policy, as evidenced by the lack of a completed discharge summary and other necessary documentation in the resident's medical record. This includes the absence of a physician order for discharge, the basis for the discharge, and information provided to the receiving provider, such as contact information, advance directive information, and comprehensive care plan goals. The resident in question had multiple diagnoses, including anxiety disorders, diabetes mellitus, cerebral infarction, aphasia following cerebral infarction, depressive episodes, chronic pain, and chronic obstructive pulmonary disease. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. Interviews with the Director of Nursing (DON) and the Administrator confirmed the absence of the required discharge documentation in the resident's medical record, despite the Administrator's involvement in the resident's transfer to another facility.
Failure to Implement Care Plan for Resident's Hand Contracture
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple medical conditions, including contracture of the right hand. The resident required a hand roll to manage the contracture, as indicated in their care plan and physician orders. However, observations over several days revealed that the hand roll was not in use, and staff were unable to locate it in the resident's room. Interviews with an LPN and a CNA confirmed that the resident was supposed to use a hand roll for the contracted hand, but it was not in place during the observations. The staff acknowledged the absence of the hand roll, which was a necessary intervention for the resident's condition, as outlined in the care plan and medical orders. This oversight indicates a failure to adhere to the established care plan and physician directives for the resident's care.
Failure to Update Care Plans for Oxygen Therapy and Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was reviewed and revised for two residents. For one resident, who required oxygen therapy due to COPD and other conditions, the care plan did not include education for the resident to notify nursing staff if there was a need to increase her oxygen. Observations revealed that the resident was adjusting her oxygen concentrator to 3 liters/minute, contrary to the physician's order of 2 liters/minute. Interviews with staff confirmed that the resident was not care planned to adjust her oxygen level and that the care plan should have been updated to include this information. Another resident, who was cognitively intact and had a history of restlessness and agitation, was found to have nasal sprays and eye drops in his room for self-administration. However, the care plan did not include an order for self-administration of the nasal spray, and there was no self-administration assessment in the resident's medical record. Interviews with staff confirmed that the resident should not have been self-administering the nasal spray at bedside without a proper order and care plan. The deficiencies highlight the facility's failure to update and revise care plans to reflect the residents' current needs and physician orders. This oversight resulted in residents managing their medications and treatments without appropriate guidance and documentation, which could potentially impact their health and safety.
Failure to Document Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to document a discharge summary for two residents, leading to a deficiency in communication of necessary information at the time of discharge. Resident #98, who had multiple diagnoses including Type 2 Diabetes Mellitus with foot ulcer and Alzheimer's Disease, was transferred to a behavioral health hospital due to behaviors and safety concerns. Despite being discharged from the behavioral hospital to another facility, no discharge summary was completed. Interviews with the social worker, Director of Nursing (DON), Assistant Administrator, and Administrator confirmed the absence of a discharge summary for Resident #98. Similarly, Resident #99, who had diagnoses including Anxiety Disorders, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was discharged without a documented discharge summary. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON and Administrator confirmed that a discharge summary should have been completed but was not present in the resident's medical record. This lack of documentation for both residents indicates a failure in the facility's discharge process.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for certified nurse aides (CNAs) as required by their policy. Specifically, the personnel records for two CNAs, hired on 12/01/2022 and 08/19/2021, lacked evidence of completed and signed annual performance evaluations within the past 12 months. The facility's policy mandates that each employee's job performance be reviewed and evaluated annually by the department director and reviewed by management. Interviews revealed that the Director of Nursing (DON) was responsible for conducting these evaluations but had not completed or signed off on any CNA performance evaluations, despite being present during the evaluations. The Human Resources representative confirmed the absence of signed evaluations for the two CNAs in question.
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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