Mid City Community Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Baton Rouge, Louisiana.
- Location
- 4005 North Blvd, Baton Rouge, Louisiana 70806
- CMS Provider Number
- 195505
- Inspections on file
- 28
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mid City Community Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow food safety standards for storage, labeling, dating, and discarding of food, as well as for documenting food temperatures for meals served to 114 residents. In the kitchen, multiple opened items in the refrigerator, dry storage, and on a seasoning shelf were undated, unlabeled, unsealed, or in poor condition, including vegetables in liquid, browning fruit, unsealed butter, bread, and clumped seasoning. The cook and dietary manager acknowledged that these items should have been sealed, labeled, dated, or discarded and confirmed that required food temperatures were not documented for several consecutive meals. The administrator confirmed that all kitchen staff were expected to ensure proper labeling, dating, and temperature documentation.
A resident admitted with a diagnosis of PTSD did not have a trauma‑informed, person‑centered care plan addressing this condition, including measurable objectives or timeframes. Review of the clinical record showed no PTSD‑related care plan, and an LPN and two CNAs reported they were unaware of the PTSD diagnosis or the resident’s potential triggers for a mental health crisis. The DON confirmed that the resident’s care plan failed to accurately reflect the resident’s status.
Surveyors found an unlabeled medication cup containing multiple unidentified white capsules in the top drawer of a medication cart. An LPN acknowledged the capsules were likely probiotics left from a prior shift and confirmed they should have been stored in a properly labeled container. The DON and administrator both stated that all medications on medication carts must be labeled, that nurses are responsible for cleaning and checking their carts each shift, and that medications should not be removed from labeled bottles for separate storage.
A resident with a PEG tube, who was under Enhanced Barrier Precautions, received incontinent care from a CNA who failed to wear a gown as required by facility policy. The CNA acknowledged not using the appropriate PPE, and the DON confirmed that staff are expected to follow EBP protocols during high-contact care activities.
A resident with morbid obesity and cognitive intactness was repeatedly found with her call light out of reach, requiring her to yell for assistance. Staff confirmed the call light was often inaccessible, and the DON acknowledged the expectation for call lights to be within reach.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect coding of functional abilities and medications. One resident was incorrectly coded as independent in certain ADLs, while another was inaccurately coded for anticoagulant use instead of antiplatelets. Staff interviews confirmed these discrepancies.
A facility failed to conduct ordered HGBA1C tests for a diabetic resident. Despite a physician's order for quarterly tests starting in November 2024, the last recorded test was in October 2024. The resident's care plan required lab work to be obtained as ordered, but this was not followed. Interviews confirmed the absence of the required tests.
The facility failed to make the results of the most recent complaint survey available for resident review. During an observation, it was found that the Survey Results folder near the entrance contained outdated information, missing the survey results from a complaint survey conducted earlier in the year. The facility's administrator confirmed the absence of these results, potentially affecting the 104 residents in the facility.
A facility failed to prevent multiple incidents of resident-to-resident physical abuse, involving cognitively intact residents with behavioral issues. Despite immediate staff intervention and separation of residents, the facility's measures were insufficient to prevent recurring aggressive interactions, highlighting a deficiency in managing resident behavior and ensuring safety.
The facility failed to report multiple incidents of physical abuse between residents to the administrator and state agency within the required timeframe. In one case, a resident punched another, resulting in a fracture, but the incident was not reported immediately. Another incident involved a resident slapping another, which was reported internally but not to the state. A third incident involved scratching, which was also not reported to the state. The administrator at the time did not consider these incidents as abuse, leading to a delay in reporting.
The facility failed to conduct PASARR Level II evaluations for two residents who were diagnosed with new psychiatric conditions after admission. Despite having new diagnoses of Schizophreniform Disorder, Unspecified Psychosis, and Bipolar Disorder, the required evaluations were not completed. Interviews revealed confusion among staff regarding responsibility for initiating the PASARR process, contributing to the oversight.
The facility failed to manage resources effectively, leading to deficiencies in PASRR Level II evaluations for residents with new mental illness diagnoses and delayed reporting of physical abuse incidents. Staff interviews revealed confusion over responsibilities, resulting in unreported abuse incidents and delayed communication to the administrator.
Two residents with cognitive disorders were involved in a physical altercation, and the facility failed to notify the on-call NP immediately as required by policy. The incident was reported to an LPN, but the NP was not informed until two days later when one resident showed signs of injury.
A facility failed to protect a resident from verbal and mental abuse by a CNA, who exhibited rude and aggressive behavior during care. The resident, with moderate cognitive impairment and significant physical needs, felt worthless and tearful due to the CNA's harsh tone and negative attitude. The Director of Nursing and Administrator confirmed the resident was not treated with respect and dignity.
The facility failed to incorporate PASRR Level II recommendations into the care plans for three residents with psychiatric diagnoses, including training in daily living skills, crisis intervention plans, and outpatient therapy. Staff interviews confirmed the lack of documentation and implementation of these services.
The facility failed to maintain a clean kitchen environment, with slugs and food debris observed on the floor and under appliances. Kitchen staff confirmed the floor had not been cleaned nightly as required, affecting 109 residents who received food from this kitchen.
The facility failed to implement PASRR Level II recommendations and ensure MDS coding accuracy for three residents, leading to a lack of necessary services such as training in daily living skills and outpatient therapy. Staff interviews revealed disorganization and unclear responsibilities regarding PASRR document handling.
The facility failed to accurately code a resident's MDS for PASRR Level II, despite the resident having a serious mental illness. This error was confirmed by both the MDS Coordinator and the Director of Nursing.
The facility failed to follow a physician's order to provide a house supplement with meals three times daily for a resident who was cognitively intact. Observations and interviews confirmed that the supplement was not provided on multiple occasions, despite being ordered.
A resident reported that his food was often served cold and his requests to have meals reheated or substituted were not honored. Interviews with staff confirmed that the resident's requests were sometimes missed by the kitchen staff, leading to a failure in providing appealing meal options of similar nutritive value.
The facility failed to ensure that a resident's code status was consistently documented across all medical records. The resident's electronic health record indicated a full code status, while the hard chart and an advanced directive form indicated a DNR status. Interviews confirmed that the records should match to reflect the resident's wishes accurately.
The facility failed to ensure staff wore proper PPE while providing catheter care for a resident on Enhanced Barrier Precautions (EBPs). A CNA was observed cleaning a resident's catheter without wearing a gown, despite the resident having a physician's order for EBPs. The Director of Nursing confirmed that staff should wear gloves and a gown during such care.
Failure to Maintain Safe Food Storage and Temperature Documentation
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with food safety standards related to storage, labeling, dating, and discarding of food, as well as documentation of food temperatures. During a kitchen tour with the cook, surveyors observed multiple improperly stored and unlabeled food items in the walk-in refrigerator, including an undated and unlabeled clear gallon bag of opened purple cabbage and sliced carrots containing a purple liquid, an undated and unsealed half-used large stick of butter, an undated opened half-full bag of browning green grapes on the vine, an undated and unlabeled gallon bag of garlic toast, a half-cut unsealed orange on a refrigerator shelf, and an open undated container of beef base. In dry storage, they found an opened, undated bag of sugar. On the seasoning shelf next to the stove, they observed an opened and undated 5-pound bag of grits, a hard piece of toasted bread lying on the shelf, and a white, unlabeled and undated canister of clumped yellow seasoning. The cook confirmed that all opened food items should have been sealed, labeled, and dated, and acknowledged that the cabbage and carrots, grapes, and half orange should have been discarded and not available for resident consumption. Further review of food temperature logs with the dietary manager showed missing documentation of food temperatures for multiple meals over several consecutive days, including no recorded temperatures for some breakfasts, lunches, and dinners. The dietary manager stated that 114 residents were served from the kitchen and that he was responsible for ensuring staff obtained and documented food temperatures prior to serving each meal, but acknowledged that staff did not document the temperatures as required. He also confirmed that all opened food items in the kitchen should have been sealed, labeled, and dated, and that certain items observed should have been discarded. The administrator similarly confirmed that all opened food items in the refrigerator or dry storage should have been labeled and dated and stated that he expected all kitchen staff, including the dietary manager, to oversee that food temperatures were obtained and documented and that all opened food was labeled and dated.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a trauma‑informed, comprehensive person‑centered care plan with measurable objectives and timeframes to address a resident’s diagnosis of Post‑Traumatic Stress Disorder (PTSD). Record review showed that Resident #14 was admitted with a diagnosis of PTSD, yet the most current care plan contained no documented evidence of any care plan addressing PTSD. During interviews, an LPN and two CNAs each stated they were unaware that this resident had a PTSD diagnosis and confirmed they were not familiar with any triggers that might result in a mental health crisis for the resident. The DON reviewed the resident’s care plan and confirmed that all care plans should accurately reflect the resident’s status and that this resident’s care plan did not do so.
Unlabeled Capsules Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were labeled and stored in accordance with its own policy and accepted professional principles. The facility’s written policy on labeling of medications and biologicals, last revised in October 2020, required that all medications be labeled per federal and state requirements and current pharmaceutical practices. During an observation of one of two medication carts (Cart A), surveyors found an unlabeled, clear medication cup in the top drawer containing 10 unidentified white capsules. The LPN assigned to the cart acknowledged the finding, stated the capsules were likely probiotics left from the weekend shift, and confirmed that the medications should have been in a labeled container identifying the medication. In interviews, the LPN further stated that unlabeled medications could lead to a nurse administering the wrong medications. The DON confirmed that all medications in the medication carts were required to be labeled and that staff nurses were responsible for cleaning their medication carts each shift. The administrator also stated that staff nurses should not remove medications from a labeled bottle to store in a medication cart and confirmed that it was the responsibility of staff nurses to check the medication carts each shift and ensure all medications remained labeled. No specific residents or their medical conditions were identified in relation to the unlabeled capsules.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program as required, specifically in relation to Enhanced Barrier Precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. According to the facility's policy, staff are required to wear gloves and a gown during high-contact resident care activities, such as changing briefs, for residents on EBP. The resident in question had a physician order and care plan in place mandating EBP, including the use of appropriate personal protective equipment (PPE) during contact care. On the date of observation, a certified nursing assistant (CNA) was seen changing the resident's brief without wearing a gown, despite signage above the resident's bed and facility policy clearly indicating the requirement for both gloves and a gown during such care. The CNA confirmed during an interview that she did not wear the appropriate PPE and acknowledged the resident's PEG tube status. The Director of Nursing (DON) also confirmed that staff are expected to wear the required PPE when providing incontinent care to residents with indwelling medical devices.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, who was admitted with a diagnosis of morbid obesity and was cognitively intact with a BIMS score of 14, was observed multiple times with her call light on the floor behind her bed, making it inaccessible. Despite being independent with eating, the resident was dependent on staff for all other activities of daily living (ADL) care and reported having to yell for assistance when the call light was out of reach. Interviews with staff confirmed the issue, with an LPN acknowledging that call lights should always be within reach and verifying that the resident's call light was frequently not accessible. The Director of Nursing (DON) was informed of these observations and confirmed the expectation that staff should keep call lights within reach of residents. This repeated failure to ensure the call light was accessible indicates a lapse in meeting the resident's needs and preferences as required.
Inaccurate MDS Assessments for Functional Abilities and Medications
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in coding their functional abilities and medication use. Resident #4 was admitted to the facility and had a Significant Change MDS assessment with an ARD of 02/25/2025, which inaccurately coded her as independent in toileting hygiene, showering/bathing, and putting on/taking off footwear. Interviews with the resident and staff, including an LPN and the MDS coordinator, confirmed that Resident #4 was actually dependent on assistance for these activities. The Director of Nursing also verified the inaccuracies in the coding. Resident #50's Quarterly MDS assessment inaccurately coded him as receiving anticoagulants, while his physician orders indicated he was prescribed antiplatelet medications, specifically Aspirin and Clopidogrel. The MDS coordinator and the Director of Nursing confirmed that the resident's MDS assessment should not have included anticoagulants, as the medications listed were antiplatelets. These inaccuracies in the MDS assessments reflect a failure in ensuring the residents' statuses were correctly documented.
Failure to Conduct Ordered Laboratory Tests for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's laboratory tests were completed as ordered by the physician. A resident, who was admitted with a diagnosis of Diabetes, had a physician's order for an HGBA1C blood draw every three months starting in November 2024. However, the last recorded HGBA1C test was conducted on October 26, 2024, and there was no documented evidence of subsequent tests being performed as required. The resident's care plan included an intervention to obtain lab work as ordered, but this was not followed. Interviews with a local laboratory spokesperson and the Director of Nursing confirmed the absence of the required HGBA1C tests from admission to the present date.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results from the most recent complaint survey were readily available for resident review. This deficiency was identified during an observation on March 17, 2025, at 9:30 a.m., when the Survey Results folder located near the entrance of the facility was reviewed. The folder contained the last survey dated April 18, 2024, but lacked the documented evidence of the survey results from the complaint survey conducted on February 11, 2025. An interview with the facility's administrator confirmed the absence of the most recent survey results in the folder. This oversight had the potential to affect the 104 residents currently residing in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple incidents of aggression among residents. Resident #1, who was cognitively intact and diagnosed with schizophrenia, was involved in several altercations. On one occasion, Resident #1 punched Resident #2 in the face multiple times, leading to a fracture in Resident #1's hand. Prior to this, Resident #1 had also been involved in an incident with Resident #4, where he scratched Resident #4's arm. These incidents indicate a pattern of aggressive behavior that was not adequately managed by the facility. Resident #2, also cognitively intact, was involved in an altercation with Resident #3, where he slapped Resident #3 on the forehead. This incident was witnessed by a CNA, who reported it immediately. Despite the immediate separation of the residents and assessment for injuries, the facility's failure to prevent these incidents highlights a deficiency in managing resident interactions and ensuring a safe environment. The facility's incident logs and interviews with staff and residents reveal that these aggressive interactions were not isolated events. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents of physical aggression. The staff's response to these incidents, while prompt, did not prevent the recurrence of similar events, indicating a need for more effective measures to manage resident behavior and prevent abuse.
Failure to Timely Report Physical Abuse Incidents
Penalty
Summary
The facility failed to report allegations of physical abuse to the administrator and the state agency within the required timeframe for four residents involved in separate incidents. The first incident involved a physical altercation between two residents, where one resident punched the other in the face multiple times after being poked with a reacher tool. This incident was not reported to the administration or the state agency immediately, as required by the facility's policy. The staff member who witnessed the altercation reported it to a Licensed Practical Nurse (LPN), but the LPN did not escalate the report until two days later when the resident who punched the other was diagnosed with a fracture. In another incident, a resident slapped another resident in the face, which was immediately reported to an LPN by a Certified Nursing Assistant (CNA). The LPN then reported the incident to the nurse practitioner and the administrator on the same day. However, the administrator at the time did not report the incident to the state agency, as they did not consider it to be physical abuse. A third incident involved a resident who scratched another resident, resulting in a deep laceration. This incident was reported to the nurse practitioner, Director of Nursing (DON), and responsible party the following morning, but not to the state agency. The administrator at the time was aware of all these incidents but failed to report them to the state agency, believing they did not constitute physical abuse.
Failure to Conduct PASARR Level II Evaluations for Residents with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that residents with newly identified mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. Specifically, two residents were identified with new psychiatric diagnoses after their initial admission and Level I screening. Resident #1 was diagnosed with Schizophreniform Disorder and later with Unspecified Psychosis, while Resident #2 was diagnosed with Bipolar Disorder. Despite these new diagnoses, no Level II evaluations were conducted for either resident, which is a requirement when a new serious mental disorder is identified. Interviews with facility staff revealed a lack of clarity regarding the responsibility for initiating the PASARR process following new psychiatric diagnoses. The social worker, S11SW, and the administrator, S1ADM, both expressed uncertainty about who should complete the necessary assessments and submit the required documentation for Level II evaluations. The psychiatric nurse practitioner, S10PNP, confirmed that while she was responsible for assessing and treating psychiatric conditions, she was not tasked with submitting PASARR documentation. This lack of role clarity contributed to the oversight in not conducting the required Level II evaluations for the residents in question.
Deficiencies in Resource Management and Abuse Reporting
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in several deficiencies. Two residents with newly diagnosed mental illnesses were not reevaluated for PASRR Level II determinations. Specifically, one resident was diagnosed with Unspecified Psychosis, and another with Bipolar Disorder, yet no documentation indicated that a Level II evaluation and determination had been submitted for either resident. Interviews with staff revealed a lack of clarity regarding who was responsible for completing these assessments and submitting the necessary paperwork. Additionally, the facility did not report allegations of physical abuse to the state agency within the required timeframe. Four residents were involved in incidents that were not reported immediately, as required. One incident involved a cognitively intact resident who punched another resident, resulting in a fracture. Despite being aware of these incidents, the responsible staff did not report them to the state agency, citing a misunderstanding of what constituted physical abuse. Furthermore, the facility failed to report incidents of physical abuse to the administrator immediately. In one case, a CNA witnessed an altercation between two residents and reported it to an LPN, who did not escalate the report until two days later when a resident's injury was noted. The administrator confirmed that the incident should have been reported immediately but was not. Interviews with staff indicated a lack of understanding and communication regarding the reporting process for abuse incidents.
Failure to Timely Notify Nurse Practitioner of Resident Altercation
Penalty
Summary
The facility failed to ensure timely communication of a significant change in status to the nurse practitioner for two residents involved in an altercation. Resident #1, diagnosed with Schizophreniform Disorder, and Resident #2, diagnosed with Bipolar Disorder, were involved in a physical altercation where Resident #2 hit Resident #1 with a reacher tool, and Resident #1 retaliated by punching Resident #2. The incident was immediately reported by the CNA to the LPN on duty, but the on-call nurse practitioner was not notified until two days later when Resident #1 began to show signs of swelling in his right hand. The facility's policy requires that the attending or on-call physician be notified immediately in the event of an accident or incident involving a patient. However, the LPN admitted to delaying the notification to the nurse practitioner, which was confirmed by the nurse practitioner who reviewed her call logs and found no record of being informed about the incident on the day it occurred. This delay in communication represents a failure to adhere to the facility's policy on notifying changes in a resident's condition or status.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a staff member. The incident involved a moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome, who was observed to become visibly tense and tearful when a CNA entered her room. The CNA rushed through care and became argumentative with a rude, aggressive tone when the resident requested to have her teeth brushed. This interaction left the resident feeling worthless and tearful, as she reported that the CNA and other staff members often spoke to her with harsh tones and exhibited negative attitudes and body language towards her. The resident's clinical record revealed she required significant assistance for transfers and activities of daily living due to her condition. During an interview, the resident stated that the CNA was rough when assisting her with care and would respond rudely when asked to be gentler. The resident expressed that the CNA's tone, body language, and facial expressions made her feel judged and like a burden. She also reported that the CNA would rush through her care and not meet all her needs, leaving her feeling ignored and with a negative attitude. The resident's roommate corroborated these observations, stating that the CNA spoke to the resident in a rude manner and made it clear she did not want to provide the requested assistance. The Director of Nursing and the Administrator both confirmed that staff should handle residents with respect and dignity, and agreed that the resident was not treated appropriately. The report concluded that the facility failed to protect the resident's right to be free from verbal and mental abuse, resulting in psychosocial harm.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into the residents' assessment, care planning, and transitions of care for three residents. Resident #12 was admitted with diagnoses including Schizoaffective Disorder and Bipolar Type. The PASRR Level II Summary recommended services such as training in activities of daily living, independent living skills, and outpatient therapy, none of which were documented or implemented in the resident's care plan. Interviews with staff confirmed the lack of documentation and implementation of these services for Resident #12. Resident #24, admitted with Schizoaffective Disorder and cognitive function issues, also had recommendations for training in independent living skills, a crisis intervention plan, and outpatient therapy. Similar to Resident #12, there was no documented evidence that these services were created or implemented in the resident's care plan. Interviews with staff confirmed the absence of these services for Resident #24. Resident #63, with diagnoses including Major Depressive Disorder and Paranoid Schizophrenia, had recommendations for training in independent living skills, a crisis intervention plan, and outpatient therapy. The clinical record and care plan for Resident #63 showed no evidence of these services being provided. Interviews with the resident and staff confirmed the lack of implementation of the recommended services. The facility administrator acknowledged that the facility did not provide the services indicated in the PASRR Level II Determination Letters for any of the Level II residents currently in the facility.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store, prepare, and distribute foods under sanitary conditions by not maintaining a clean kitchen environment. During an initial tour of the kitchen, a slug was observed moving on the floor under the mixer, and three slugs were seen behind the plate warmer. Food debris was found on the floor throughout the kitchen, including under the oven, stove, plate warmer, steam table, and dishwasher. Four french fries were observed on the floor between the steam table and plate warmer, which were confirmed to be from the previous night's supper. Interviews with kitchen staff confirmed that the kitchen floor had not been cleaned nightly as required, and the kitchen staff were responsible for this task. The facility had 109 residents who received food from this kitchen.
Failure to Implement PASRR Recommendations and Ensure MDS Coding Accuracy
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable physical, mental, and psychosocial well-being of its residents. Specifically, the facility did not incorporate recommendations from PASRR Level II Determinations and PASRR Evaluation Reports into the residents' assessments, care plans, and transitions of care for three residents. For instance, Resident #12, who was diagnosed with Schizoaffective Disorder and Bipolar Type, did not have documented evidence of receiving recommended services such as training in activities of daily living, independent living skills, or outpatient therapy. Similarly, Resident #24 and Resident #63 also lacked documented evidence of receiving their recommended services, including crisis intervention plans and outpatient therapy, as indicated in their PASRR Level II Determinations. Interviews with facility staff revealed a lack of clarity and responsibility regarding the handling and processing of PASRR documents. The administrator (S1ADM) and social workers (S5SSD) were unsure of their roles in ensuring that PASRR recommendations were implemented. The administrator admitted to not understanding the necessary services indicated in the PASRR determinations, while the social worker stated that PASRR documents were scattered in various locations, making them difficult to locate and process. This disorganization contributed to the failure to implement the required services for the residents. Additionally, the facility failed to ensure the coding accuracy for Minimum Data Set (MDS) assessments regarding PASRR Level II. For example, Resident #12's MDS assessment incorrectly indicated that the resident had not been evaluated by Level II PASRR, despite having a documented PASRR Level II Summary and Determination Notice. Interviews with the MDS coordinator (S13MDSC) and the Director of Nursing (S2DON) confirmed that they were not provided with the necessary documentation to code the MDS accurately. The administrator acknowledged that there was no system in place to ensure correct MDS coding and the provision of required services for residents with PASRR Level II determinations.
Inaccurate Coding of PASRR Level II in MDS Assessment
Penalty
Summary
The facility failed to ensure a resident's assessment accurately reflected the resident's status by not correctly coding the Minimum Data Set (MDS) for PASRR Level II. Specifically, Resident #12, who was admitted with a diagnosis of Schizoaffective Disorder, Bipolar Type, had an Annual MDS assessment that incorrectly indicated 'No' for PASRR Level II evaluation despite having a serious mental illness. This discrepancy was confirmed through interviews with the MDS Coordinator and the Director of Nursing, who both acknowledged that the MDS should have been coded as 'Yes' for PASRR Level II evaluation.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to implement a comprehensive person-centered plan of care by not following the physician's orders for a resident's nutritional needs. Resident #45, who was cognitively intact with a BIMS score of 15, was admitted to the facility and had a physician's order to receive a house supplement with meals three times daily. However, observations and interviews revealed that the resident did not receive the house supplement with his meals on multiple occasions. Specifically, the supplement was missing from his lunch tray on 04/17/2024 and from his breakfast tray on 04/18/2024. Both the Dietary Manager and the Director of Nursing confirmed that the supplement was ordered but not provided as required.
Failure to Provide Appealing Meal Options and Reheat Food
Penalty
Summary
The facility failed to ensure that appealing options of similar nutritive value were offered to residents who chose not to eat the food initially served or who requested a different meal choice. Specifically, Resident #45, who was cognitively intact with a BIMS of 13, reported that his food was often served cold. Despite his requests to the kitchen staff to have his meals reheated or substituted, these requests were not honored. This issue was confirmed through multiple interviews with the resident, the LPN, the DON, and the Dietary Manager, all of whom acknowledged that the resident's requests were sometimes missed by the kitchen staff. Resident #45 was admitted to the facility and had a care plan that included offering food alternatives when appropriate. However, the resident consistently experienced issues with the temperature and substitution of his meals. The LPN and Dietary Manager both confirmed that the resident frequently complained about his food being cold and needing substitutes, and that these requests were sometimes overlooked by the kitchen staff. The DON also confirmed that the resident should have received alternative options and had his meals reheated upon request, but this did not occur as it should have.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that all medical records regarding a resident's code status consistently reflected the resident's wishes. Specifically, for one resident, the electronic health record indicated a full code status, while the hard chart and an advanced directive form signed by the resident indicated a Do Not Resuscitate (DNR) status. The resident, who was cognitively intact, confirmed during an interview that he wished to remain a DNR in the event of an emergency. Interviews with the nursing staff and the Director of Nursing (DON) revealed that in the event of an emergency, they would refer to the hard chart to determine a resident's code status. Both the nursing staff and the DON confirmed that the resident's hard chart and electronic health record should match to accurately reflect the resident's end-of-life wishes, which was not the case for this resident. This inconsistency in the medical records could lead to actions that do not align with the resident's documented wishes.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. Specifically, the facility did not ensure that staff wore proper Personal Protective Equipment (PPE) while providing catheter care for a resident. The facility's policy on Enhanced Barrier Precautions (EBPs) requires staff to wear gowns and gloves during high-contact care activities, including catheter care for residents with indwelling medical devices. However, during an observation, a CNA was seen providing catheter care to a resident without wearing a gown, despite the resident being on EBPs. The resident in question was admitted with diagnoses including Neuromuscular Dysfunction of the Bladder and Paraplegia and had a physician's order for EBPs. During an interview, the CNA confirmed that she did not wear a gown while providing catheter care, even though she was aware that the resident was on EBPs. The Director of Nursing also confirmed that nursing staff should wear gloves and a gown when providing catheter care for this resident. This failure to adhere to the facility's infection control policy represents a deficiency in maintaining a safe and sanitary environment.
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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