Resthaven Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bogalusa, Louisiana.
- Location
- 1301 Harrison Street, Bogalusa, Louisiana 70427
- CMS Provider Number
- 195624
- Inspections on file
- 22
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Resthaven Living Center during CMS and state inspections, most recent first.
A resident with a history of cerebral infarct, cognitive communication deficit, and moderate cognitive impairment experienced increased confusion and was transferred to the hospital. Facility policy required prompt notification of the resident representative for significant changes in condition and hospital transfers, but the assigned LPN did not notify the resident’s responsible party and did not document the transfer or any notification in the nurse’s notes. The responsible party reported learning of the hospitalization only when contacted by the hospital, and the DON confirmed that the LPN should have notified the responsible party.
Surveyors identified that two residents received incorrect medication dosages during an observed med pass, resulting in a 12% medication error rate. One LPN administered a 25 mg dose of Sertraline instead of the ordered 50 mg, while another LPN gave a 50 mg Zinc capsule instead of 220 mg and a 10 mcg Vitamin D3 tablet instead of 1250 mcg. In each case, the nurses later confirmed, after reviewing the MAR and medication packaging, that they had not verified the correct dosages before administration, contrary to facility policy requiring multiple label checks to ensure the right medication and dose.
Surveyors identified unsanitary food service conditions when an ice machine contained ice mixed with visible pink sludge, which the dietary manager acknowledged was not sanitary despite recent cleaning. In addition, a cook demonstrated washing pots and pans in a 3-compartment sink using an incorrect sequence of wash, sanitize, and rinse, while the sanitizer dispenser was installed in the middle basin labeled as the rinse sink instead of the final basin. The dietary manager and administrator both confirmed that the ice machine should be clean and that the correct 3-compartment sink process is wash, rinse, then sanitize.
Surveyors found that a bulk grease disposal container located outside behind the kitchen was in poor condition, with its lid left open and black grease accumulated on top of the container and on the surrounding concrete, mixed with leaves. The dietary manager acknowledged that the container had been in this unsanitary condition for several months, with grease present on and around it, and confirmed the lid remained open. The administrator also confirmed awareness that the lid had been left open, that rain caused grease to spill over onto the concrete, and that the container had been in poor condition for an extended period, resulting in improper containment of refuse with the potential to affect 82 residents.
Surveyors found that a resident shower room (Shower Room A) was not maintained in a sanitary and comfortable condition, with a black, fuzzy substance observed on the tile where the wall met the floor below the shower head. A CNA confirmed the substance had been present for a long time and described the room as neither comfortable nor sanitary, stating that both maintenance and the administrator were aware of the ongoing issue. The maintenance staff member acknowledged the substance had been present for months in a shower room used by residents and agreed it was not being properly maintained, and the administrator confirmed awareness of the problem and that the substance should not have been present.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required accessible call systems. One resident with moderate cognitive impairment and multiple conditions, including osteoarthritis and prior cerebral infarction, was observed with her call light on the floor, out of reach, despite being able to use it. Another resident with severe cognitive impairment, mobility issues, and diabetic polyneuropathy was observed in a geri-chair with the call light rolled up on a bedside table, also out of reach, even though she could use it to request help. Staff, including a CNA, a supervisor, and the DON, confirmed that both residents were capable of using their call lights and that facility policy requires call lights to be easily reachable at all times.
A resident’s Discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, despite nursing notes documenting that the resident left the facility via wheelchair using personal transportation and against medical advice. During interviews, the MDS nurse acknowledged the discharge status should have been coded as a discharge to home/community, and the DON stated an expectation that MDS nurses complete assessments to accurately reflect each resident’s discharge status.
A resident with documented mental health conditions, including Bipolar Disorder, Depression, and Anxiety Disorder, was readmitted and had a PASRR Level I form completed by an LPN using only hospice referral records, which did not list Bipolar Disorder. The LPN did not review the resident’s prior admission records, where Bipolar Disorder was clearly documented, resulting in a PASRR Level I that listed only Major Depression and Anxiety Disorder. Upon review, quality improvement staff and the LPN confirmed that the Bipolar Disorder diagnosis should have been included but was omitted.
A resident with an indwelling port and sacral wound infection was on Enhanced Barrier Precautions (EBP) with posted signage and physician orders requiring gown and gloves for high-contact care, including device care or use. An LPN was observed administering IV Vancomycin through the resident’s chest port while not wearing a gown, contrary to the facility’s EBP policy and the instructions on the EBP sign. In a subsequent interview, the LPN acknowledged that a gown should have been worn, and the DON confirmed that appropriate PPE is required for residents on EBP, including during IV medication administration via a port.
The facility failed to employ a certified dietary manager, as the previous manager was fired weeks ago, and the acting manager lacked the necessary certification. The administrator confirmed no staff held the required certification, potentially affecting 84 residents consuming food from the kitchen.
The facility failed to store food according to professional standards, potentially affecting 84 residents. Expired items, including cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, were found in the kitchen. The facility's policy requires safe food handling practices, but these items were not discarded as they should have been, as confirmed by S1ADM.
A resident with Glaucoma was inaccurately assessed in their MDS, which indicated clear speech and adequate vision. However, therapy notes and staff interviews confirmed the resident had slurred speech and inadequate vision. The ADON acknowledged these issues, highlighting the need for accurate MDS coding.
A facility failed to change a resident's oxygen tubing and humidifier bottle as per physician orders, which required weekly changes every Sunday night. An observation revealed that the equipment was not changed on the scheduled date, and an LPN confirmed the oversight. The DON was notified of the failure to adhere to the schedule.
The facility failed to accurately document the MAR for two residents, leading to discrepancies in their medical records. One resident's oxygen equipment was not changed as recorded, and another resident's lab test was documented without being conducted. The involved LPNs confirmed the inaccuracies, and the DON verified the errors.
The facility failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. Two CNAs were observed providing care without wearing gowns, despite facility policy and signage indicating the requirement. Interviews confirmed staff awareness of the PPE requirement, yet compliance was not maintained.
The facility did not ensure that the most recent survey results were available for resident review. An observation revealed that the State Survey Binder only contained results from 2022, missing the 2023 annual recertification and 2024 complaint surveys. Interviews with a CNA and the DON confirmed the absence of these documents, which should have been accessible to residents.
The facility did not post the current nurse staffing data, as observed on a bulletin board by the nurses' station. The report was dated the previous day, and both the Administrator and the DON confirmed the oversight, acknowledging that the current report should have been posted.
The facility failed to document neurological assessments after unwitnessed falls for two residents. Despite staff claims of performing neuro checks, no documentation was found for one resident, and incomplete documentation was found for another. The DON confirmed the absence and incompleteness of these records, indicating a failure to adhere to the facility's policy.
The facility failed to limit PRN orders for psychotropic medications to 14 days and did not indicate the duration for the PRN orders for a resident with Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety. Interviews confirmed that the facility did not follow its policy requiring prescriber evaluation and duration documentation for PRN psychotropic medications.
The facility failed to ensure accurate resident assessments. A resident diagnosed with Major Depressive Disorder had an MDS assessment that did not reflect this active diagnosis. Staff responsible for MDS assessments confirmed the inaccuracy.
The facility failed to maintain accurate records when an LPN did not document the administration of Morphine for a resident with multiple diagnoses, including Dementia and Polyosteoarthritis. The LPN confirmed administering the medication but did not record it on the MAR, as expected by the Director of Nursing.
The facility failed to designate a staff member to coordinate care with hospice representatives, resulting in an incomplete hospice binder for a resident. Interviews with staff confirmed the absence of a designated coordinator and missing hospice plan of care documents.
Failure to Notify Responsible Party of Resident’s Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of a significant change in condition and transfer to the hospital, contrary to its own policy. The facility’s policy titled “Change in a Resident’s Condition or Status” (revised May 2017) states that the resident representative must be promptly notified of changes in the resident’s medical or mental condition and when it is necessary to transfer the resident to a hospital. Resident #1 was admitted with diagnoses including cerebral infarct and cognitive communication deficit, and her son was listed as her RP. A quarterly MDS dated 02/09/2026 documented a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The facility’s Emergency Transfer Log showed that Resident #1 was transferred to the hospital in January 2026 for a change in status, specifically increased confusion. However, review of the resident’s nurse’s notes for that period revealed no documentation of the hospital transfer and no documentation that the RP was notified. In an interview, the RP stated he was not informed by the facility that the resident had been sent to the hospital or the reason for the transfer, and that he only learned of the hospitalization when the hospital called him with an update. The LPN assigned to the resident on the date of transfer confirmed that the resident was transferred due to increased confusion, acknowledged there was no documentation of the transfer or RP notification, and confirmed she did not notify the RP. The DON also confirmed that the resident was transferred due to increased confusion and that the LPN should have notified the RP of the transfer.
Medication Administration Errors Resulting in 12% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 12% during an observed medication pass. Surveyors observed 25 medication administration opportunities and identified 3 errors involving two residents. Facility policy on administering medications, revised April 2019, states that medications are to be administered safely, timely, and as prescribed, and that the individual administering the medication must check the label three times to verify the right resident, medication, dosage, time, and route before administration. For one resident, an LPN administered Sertraline HCL 25 mg by mouth instead of the ordered Sertraline HCL 50 mg once daily. The nurse later reviewed the physician’s orders and the medication card and confirmed that the dose given was incorrect and that she had failed to verify the dosage prior to administration. For another resident, a different LPN administered Zinc 50 mg instead of the ordered Zinc Sulfate 220 mg, and Vitamin D3 10 mcg instead of the ordered Vitamin D3 1250 mcg given on specific mornings. This nurse also confirmed, upon review of the physician’s orders and medication containers, that both dosages were incorrect and acknowledged she had not checked the medication dosages prior to administration. The DON stated he expected staff to check medications against physician orders prior to administration and confirmed medications should be given in the correct dosage as ordered by the physician.
Unsanitary Ice Machine and Improper Three-Compartment Sink Use
Penalty
Summary
Surveyors found that the facility failed to store, prepare, and distribute food under sanitary conditions in the kitchen, affecting the ice machine and pot and pan sanitation. During observation of the kitchen ice machine, surveyors noted a low level of ice mixed with pink sludge, including visible pink sludge in the right front corner of the machine; the dietary manager confirmed the presence of the pink sludge and acknowledged it was not sanitary, despite stating the machine had been serviced and cleaned two days earlier. In a separate observation of pot washing at the 3-compartment sink, a cook demonstrated her process and stated she washed, sanitized, and rinsed pots and pans, while the sanitation dispenser was actually installed in the second sink labeled “rinse,” rather than in the third sink. The dietary manager confirmed that the sanitizer was in the wrong compartment and that the correct sequence for the 3-compartment sink should be wash, rinse, then sanitize, and the administrator confirmed that the ice machine should not have pink sludge and that the 3-compartment sink should be used in the proper wash, rinse, sanitize order.
Improper Maintenance and Containment of Bulk Grease Disposal Container
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and containment of grease waste when they observed a large bulk grease disposal container located outside next to the facility wall behind the kitchen with its lid open. The container had a large amount of black grease on top and on the surrounding concrete area, with leaves mixed into the spilled grease. During interview, the dietary manager stated the bulk grease container was in poor condition, confirmed the lid was open, and acknowledged that grease had been present on top of the container and on the surrounding concrete area since September 2025, describing the situation as unsanitary. In a separate interview, the administrator confirmed awareness of the bulk grease container’s location and condition, stating that the lid had been left open and that rain caused grease to spill over onto the surrounding concrete, and further confirmed the container had been in poor condition for some time and needed to be removed. This deficient practice involved failure to ensure refuse containers were in good condition and that waste was properly contained, and it had the potential to affect 82 residents residing in the facility.
Failure to Maintain Sanitary and Comfortable Resident Shower Room
Penalty
Summary
The facility failed to ensure that Shower Room A was maintained in a safe, sanitary, and comfortable condition for residents, staff, and the public. During an observation on 01/13/2026 at 3:00 p.m., surveyors noted a black, fuzzy substance on the tile below the shower head where the wall tile met the floor in Shower Room A. At 3:03 p.m., a CNA (S6CNA) confirmed the presence of this substance, stated that Shower Room A was not a comfortable and sanitary environment, and reported that the black fuzzy substance had been present for a long time and was an ongoing problem. She further stated that the maintenance staff member (S7MNT) and the administrator (S1ADM) were both aware of the condition of Shower Room A. At 3:30 p.m., S7MNT confirmed he was aware that Shower Room A, which was used by residents, had a black fuzzy substance on the tile where the wall met the floor and that it had been present for months, acknowledging that the room was not maintained in a comfortable and sanitary manner. At 4:03 p.m., S1ADM also confirmed awareness of the black fuzzy substance in Shower Room A and acknowledged that it should not have been present and that the shower room should have been maintained in a comfortable and sanitary manner. No specific residents, medical histories, or clinical conditions were described in relation to the use of Shower Room A, only that it was a resident shower room used by residents and that its condition did not meet sanitary and comfort standards.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by facility policy and individual care plans. The facility’s policy on the Resident Call Light System, revised 06/2023, states that staff must ensure the call light is easily reachable by the resident. Resident #2, admitted with multiple diagnoses including bilateral primary osteoarthritis of the hip, mild neurocognitive disorder with behavioral disturbance, vertebral compression fractures, intellectual disabilities, schizophrenia, and cerebral infarction, had an MDS BIMS score of 11, indicating moderate cognitive impairment. Her care plan specified that she was to have a working and reachable call light and be encouraged to use it for assistance as needed. On 01/12/2026 at 9:40 a.m., surveyors observed Resident #2’s call light on the floor and not within her reach. During an interview at 9:50 a.m., S13CNA confirmed that Resident #2 was able to use the call light and that it was not within her reach. Resident #51, admitted with diagnoses including difficulty in walking, other lack of coordination, primary generalized osteoarthritis, type 2 diabetes mellitus with diabetic polyneuropathy, and muscle wasting and atrophy, had an MDS BIMS score of 7, indicating severe cognitive impairment. Her care plan documented that she required staff assistance with ADLs, was to have a working, reachable call light, and was to be encouraged to use the call light for assistance. On 01/12/2026 at 9:01 a.m., surveyors observed Resident #51 sitting in a geri-chair with her call light rolled up on the bedside table, not within her reach. At 9:20 a.m., S12SUP confirmed that the call light was not within the resident’s reach, stated it should have been, and confirmed that Resident #51 was capable of using the call light to call for assistance. On 01/14/2026 at 10:25 a.m., S2DON acknowledged awareness that the call lights for both residents had been found out of reach and stated that the facility’s process is for staff to place call lights within residents’ reach before exiting the room and to ensure call lights are within reach at all times.
Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s assessment accurately reflected the resident’s discharge status. Review of the Discharge MDS assessment for Resident #92, with an ARD of 12/10/2025, showed the resident was coded as having been discharged to a short-term general hospital. However, nursing notes documented that on 12/10/2025 at 11:20 a.m., the resident left the facility via wheelchair using his own transportation. In an interview, the MDS nurse (S9MDS) confirmed that the resident had left the facility against medical advice and that the Discharge MDS was inaccurately coded, stating it should have indicated a discharge to home/community instead of to a hospital. The DON (S2DON) stated he expected MDS nurses to complete all assessments to accurately reflect each resident’s discharge status. This inaccurate coding of the discharge location for Resident #92 on the Discharge MDS constituted the identified deficiency in ensuring accurate resident assessments.
Failure to Include Bipolar Disorder Diagnosis on PASRR Level I Evaluation
Penalty
Summary
The facility failed to ensure that a resident with an identified mental health diagnosis was accurately referred for a PASRR Level II evaluation, resulting in an incomplete PASRR Level I form. The resident was initially admitted with documented diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder, and later readmitted with the same conditions. However, review of the PASRR Level I form completed on 07/30/2025 showed that only Major Depression and Anxiety Disorder were listed, and the Bipolar Disorder diagnosis was omitted. The LPN who completed the PASRR Level I form stated she relied solely on clinical records from the referring hospice agency, which did not list Bipolar Disorder, and did not review the resident’s initial admission records because she did not have access to them at that time. Upon later review of the initial admission clinical records, both the LPN and the quality improvement staff member confirmed that Bipolar Disorder had been an established diagnosis and should have been included on the PASRR Level I form but was not.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, revised in 03/2024, states that EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO), including device care or use such as central lines and ports. Resident #95’s clinical record showed an order to implement and maintain EBP during high-contact care starting 11/19/2025, an order allowing access to a port dated 08/24/2023, and an order for daily IV Vancomycin for a sacral wound infection dated 01/02/2026. An EBP sign was posted on the resident’s door, instructing that staff must wear gloves and a gown for high-contact activities including device care or use. On 01/13/2026 at 1:02 p.m., a surveyor observed an LPN (S4LPN) administering IV Vancomycin via the resident’s right chest port without wearing a gown, despite the EBP signage and the resident’s active EBP orders related to his port and wounds. During an interview immediately afterward, the LPN confirmed that the resident was on EBP due to his port and wounds and acknowledged that she should have worn a gown while providing direct resident care but did not. Later, the DON (S2DON) stated that when a resident is on EBP, he expected staff to wear appropriate PPE when providing direct resident care, confirmed that EBP is initiated for residents with indwelling medical devices such as a port, and further confirmed that appropriate PPE should be worn during IV medication administration through a port.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to manage the food and nutrition service, as evidenced by the absence of a certified dietary manager. This deficiency was identified during interviews and record reviews, revealing that the previous dietary manager had been fired 2-3 weeks prior, and the acting manager, S3DA, did not possess certification in food service or dietary management. Furthermore, the facility administrator, S1ADM, confirmed that neither he nor any other staff members held the necessary certification. This lack of qualified personnel had the potential to impact the 84 residents who consumed food prepared by the facility's kitchen.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 84 residents who were served meals from the kitchen. During an observation of the kitchen food preparation area, several expired items were found, including opened containers of cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, all of which had passed their manufacture expiration dates. The facility's policy on Food Receiving and Storage, revised in 2014, mandates that foods be received and stored in compliance with safe food handling practices. An interview with S1ADM confirmed that 84 residents eat from the kitchen and acknowledged that the expired items should have been discarded but were not.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status, specifically for one resident diagnosed with Glaucoma. The resident's quarterly MDS inaccurately indicated clear speech and adequate vision, despite therapy progress notes and multiple staff interviews confirming the resident had slurred speech and inadequate vision. Interviews with the resident and various staff members, including a physical therapist, occupational therapist, and speech therapist, consistently noted the resident's slurred speech and vision issues. The Assistant Director of Nursing also acknowledged the resident's slurred speech and vision loss, emphasizing the importance of accurate MDS coding.
Failure to Change Oxygen Tubing and Humidifier Bottle as Scheduled
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. The resident's physician orders required that the oxygen tubing and humidifier bottle be changed every Sunday night and as needed for contamination. However, an observation on 12/09/2024 revealed that the oxygen tubing and humidifier bottle were labeled with the date 12/01/2024, indicating they had not been changed as required on 12/08/2024. An LPN confirmed the oversight during an interview, acknowledging that the change should have occurred but did not. The Director of Nursing was also informed of the failure to adhere to the scheduled change.
Inaccurate Documentation in MAR for Two Residents
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for two residents, leading to discrepancies in their medical records. For Resident #3, who was admitted with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma, the MAR indicated that oxygen tubing and humidifier bottles were changed on a specific date. However, observations revealed that the equipment was not changed as documented, with the items still labeled from a previous date. The LPN responsible for the documentation confirmed that the change did not occur as recorded. Similarly, for Resident #290, who was on long-term anticoagulant therapy, the MAR inaccurately reflected that a PT/INR lab test was collected on a certain date. However, there were no lab results to support this entry, and the laboratory confirmed that no such test was conducted on that date. The LPN involved acknowledged the error in documentation, and the Director of Nursing confirmed the inaccuracies in the MAR, emphasizing that all records should accurately reflect the services provided.
Inadequate PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members while providing care to a resident under Enhanced Barrier Precautions (EBP). Specifically, the facility's policy on transmission-based precautions required staff to wear gloves and gowns during high-contact activities such as dressing and transferring residents. However, during an observation, two certified nursing assistants (CNAs) were seen dressing, emptying a urostomy bag, and transferring a resident without wearing the required gowns. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the staff was aware of the requirement to wear gowns when providing direct care to residents on EBP, yet they failed to comply with this protocol. The resident in question had been admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and ileostomy status, necessitating the use of EBP to prevent infection transmission. Despite the presence of signage on the resident's door indicating the need for PPE, the staff did not adhere to the facility's infection control policy, leading to the identified deficiency.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results of the most recent annual survey and complaint surveys were available for resident review. During an observation on December 8, 2024, it was noted that the State Survey Binder at the nurse's station only contained survey results from December 8, 2022. Interviews with a CNA and the Director of Nursing confirmed that all survey results were supposed to be kept in this binder. However, upon review, it was confirmed that the survey results from the annual recertification survey dated November 29, 2023, and the complaint surveys dated April 23, 2024, and May 31, 2024, were missing from the binder and had not been made available for resident review as required.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that the current nurse staffing data was posted daily, which had the potential to affect any of the 85 residents residing in the facility. On the morning of December 9, 2024, an observation revealed that the Daily Staffing Report posted on the bulletin board by the nurses' station was dated December 8, 2024, indicating it was not current. Interviews conducted with the Administrator (S1ADM) and the Director of Nursing (S2DON) confirmed that the posted staffing report was outdated and acknowledged that the current report had not been posted as required.
Failure to Document Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure services were provided to meet quality professional standards for two residents reviewed for falls. Specifically, the facility did not document neurological assessments after unwitnessed falls for Resident #1 and Resident #3. Resident #1, who had diagnoses including repeated falls, cerebrovascular disease, and hemiplegia, experienced unwitnessed falls on three occasions. Despite claims from staff that neurological checks were performed, no documentation was found in the clinical records. Interviews with the LPNs and the DON confirmed the absence of documented neurological assessments for these incidents. Resident #3, who had diagnoses including polyosteoarthritis, dementia, and difficulty in walking, experienced multiple unwitnessed falls. The facility's documentation of neurological assessments for these falls was incomplete. The DON confirmed that neuro checks should be completed and documented at specific intervals following unwitnessed falls, but the records for Resident #3 did not meet these requirements. This lack of proper documentation indicates a failure to adhere to the facility's policy on falls and neurological assessments.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications. Specifically, the facility did not limit PRN orders for psychotropic drugs to 14 days and did not indicate the duration for the PRN orders for one resident. Resident #3, who had diagnoses including Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety, had active PRN orders for Lorazepam and Temazepam without documented end dates. The facility's policy required that PRN psychotropic medications be limited to 14 days and that the prescriber evaluate the resident before extending the order and provide a duration for the pharmacotherapy. However, this policy was not followed for Resident #3's medications. Interviews with the Consultant Pharmacist and the Director of Nursing (S1DON) confirmed that PRN orders for psychotropic medications should be limited to 14 days and require a prescriber evaluation before extension. The Consultant Pharmacist acknowledged the oversight, while the S1DON was unable to confirm whether hospice PRN medications were subject to the same 14-day limitation. This failure to adhere to the facility's policy resulted in the deficiency noted in the report.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status. Specifically, Resident #4, who was admitted to the facility and diagnosed with Major Depressive Disorder on 03/02/2024, had an inaccurate quarterly MDS assessment with an ARD of 03/14/2024. The diagnosis of Major Depressive Disorder was not coded as an active diagnosis in Section I of the MDS. During an interview, S2MDS, who is responsible for MDS assessments, confirmed that the diagnosis should have been accurately coded. S1DON also confirmed that the MDS should reflect all active diagnoses accurately.
Failure to Document Administered Narcotic Medication
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards and practices for one of the residents reviewed. Specifically, the facility did not ensure that an LPN documented the administration of narcotic medications on a resident's Medication Administration Record (MAR). The resident, who had diagnoses including Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking, was readmitted to the facility and required Morphine for pain management. On the specified date, the LPN removed Morphine from stock but did not document its administration on the MAR. During a phone interview, the LPN confirmed administering the medication but could not recall if it was documented. The Director of Nursing reviewed the MAR and confirmed that staff are expected to document any administered medication.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to designate a member of the interdisciplinary team to coordinate care with hospice representatives, as required by their policy. This deficiency was evidenced by the absence of up-to-date hospice binders for a resident who was readmitted to the facility and admitted to hospice services. Specifically, the hospice binder for the resident lacked the most recent hospice plan of care documents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that there was no designated staff member responsible for coordinating hospice care and that the hospice binder was incomplete.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
