Savoy Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mamou, Louisiana.
- Location
- 906 Cherry Street, Mamou, Louisiana 70554
- CMS Provider Number
- 195619
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Savoy Care Center during CMS and state inspections, most recent first.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
A resident with severe cognitive impairment and multiple neurologic and vascular diagnoses was observed on multiple occasions lying on an air mattress that was too small for the bedframe, resulting in the resident’s feet and head extending beyond the mattress and a gap of about one foot between the mattress and the bedframe. A CNA, the ADON, and the DON each confirmed that the mattress did not properly fit the bedframe and did not accommodate the resident’s height.
The facility did not ensure a fall mat was in place as ordered for a resident with severe cognitive impairment and failed to implement an increased water flush order for another resident receiving PEG tube feeding, as confirmed by staff observations and interviews.
A resident with multiple chronic conditions did not have the Medical Director timely notified of the Registered Dietician's recommendations for changes in tube feeding and protein supplementation. Although the recommendations were faxed, there was no follow-up call as required, and no response was received until after the resident's death in the hospital.
A facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A CNA verbally abused a resident, causing emotional distress. Additionally, a resident with aggressive behavior physically abused two other residents, and the facility neglected a resident by not following the required two-person assist protocol during transfers. These incidents were not properly addressed or reported, indicating systemic issues in ensuring resident safety.
A facility failed to report multiple abuse incidents involving both staff and residents. A CNA verbally abused a resident, and a resident with severe cognitive impairment physically assaulted two other residents. Despite documentation and awareness of these incidents, the facility did not report them to the State Agency, leading to an Immediate Jeopardy situation.
The facility failed to investigate allegations of abuse involving three residents. A resident reported verbal abuse by a CNA, but the facility did not consider it an abuse allegation and failed to investigate. Another resident was hit by a fellow resident, but the DON did not investigate the physical aspect of the altercation. Additionally, a resident with severe cognitive impairment had her hair pulled by another resident, but the incident was not investigated as abuse. These failures resulted in an Immediate Jeopardy situation.
The facility did not provide water to 10 residents during lunchtime in Hall X dining room, offering only juice and milk with their meals. Observations and interviews confirmed that water was not included on meal trays and was only provided upon specific request.
The facility failed to effectively manage resources, leading to multiple instances of abuse and neglect. A resident was verbally abused by a CNA, while two residents experienced physical abuse from another resident. Additionally, a resident was neglected during a transfer. The facility lacked an effective system for reporting and investigating these incidents, resulting in a failure to recognize and address abuse and neglect.
A facility failed to ensure consistent documentation of a resident's advance directive. The resident, with multiple medical conditions, was listed as Full Code in the electronic record, while the physician's orders and care plan indicated a DNR status. Staff interviews confirmed reliance on the electronic record for code status, and the inconsistency was acknowledged by the DON.
A facility failed to complete a PASARR Level II screening for a resident who was diagnosed with Bipolar Disorder after admission. Initially admitted with a Level I screening indicating no mental illness, the resident's new diagnosis required a Level II screening, which was not conducted, as confirmed by the DON.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with a history of falls was repeatedly observed without a required fall mat, while another had a fall mat improperly placed. Additionally, a resident requiring two-person assistance for bed mobility experienced a fall when care was provided by one CNA alone. These failures were confirmed by facility staff.
A facility failed to provide proper pressure ulcer care for a resident with a Stage 3 ulcer. The treatment nurse contaminated gloves by placing them on an unclean bedside table and did not follow proper infection control procedures, such as removing soiled gloves and sanitizing hands before continuing wound care. This compromised the resident's treatment and increased the risk of infection.
A facility failed to administer a resident's enteral flush according to physician orders. The resident, with multiple medical conditions including dysphagia, had an order for Glucerna 1.5 cal at 60cc/hour with 35cc/hour water flushes. Observations showed the water flush was set at 30cc/hour instead of the prescribed 35cc/hour, confirmed by the ADON.
A resident with severe cognitive impairment and shortness of breath was not provided with oxygen therapy as ordered by the physician. The resident's oxygen was set at 3 liters per minute instead of the prescribed 2 liters per minute. Facility staff, including an LPN and the DON, confirmed the discrepancy and acknowledged the need for adherence to physician orders for oxygen administration.
An LPN failed to maintain accurate documentation of controlled substances, resulting in discrepancies between the narcotic log and medication blister packs for two residents. The LPN admitted to not signing out the medications on the narcotic record log sheet after administration, and the DON confirmed that all controlled medications should be signed off immediately after administration.
A resident with cognitive impairment and dependency on staff for daily activities was found without a call bell within reach on multiple occasions, despite being able to use it to request assistance. Facility staff confirmed the call bell's inaccessibility and the resident's ability to use it, highlighting a deficiency in accommodating the resident's needs.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
Incompatible Mattress and Bedframe for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s mattress was compatible with and properly fit the bedframe, as required by the expectation that all bed frames, mattresses, and bed rails be regularly inspected for safety and that mattresses attach safely to the bed frame. The affected resident had an admission date of 12/07/2023 and diagnoses including Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease, with a Quarterly MDS BIMS score of 6 indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., surveyors observed the resident lying in bed with his feet hanging off the mattress, which appeared too small for the bedframe. On 03/24/2026 at 10:12 a.m., further observation showed the resident lying on his back with his head elevated on an air mattress that did not fit the bedframe properly, leaving approximately a 1-foot gap between the top of the bedframe and the head of the mattress, with the resident’s head partially above the mattress. At 12:48 p.m., a CNA confirmed the mattress did not fit the bedframe and explained that pulling the resident and mattress up in the bed would create a gap at the footboard. At 1:00 p.m., the ADON confirmed the mattress was not accommodating to the resident’s height and should be. At 3:00 p.m., the DON observed that the air mattress was approximately 1 foot smaller than the bedframe and confirmed that the bed was not accommodating the resident and that the mattress did not fit the bedframe properly.
Failure to Follow Physician Orders for Fall Prevention and Tube Feeding Care
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with severe cognitive impairment and total dependence on staff for self-care and transfers, a physician's order and care plan intervention required a fall mat to be in place at the bedside following a recent fall. However, during observation, the fall mat was not present, and facility staff confirmed it should have been in place as ordered. For another resident who was dependent on staff for all activities of daily living and received nutrition and hydration via PEG tube, the registered dietician recommended, and a physician's order was entered, to increase the water flush from 30ml/hr to 40ml/hr. Despite this, observations on multiple occasions showed the water flush remained set at 30ml/hr. Staff interviews confirmed the order had not been implemented as required, and nursing staff had not verified or adjusted the pump settings to ensure the resident received the prescribed water flush.
Failure to Timely Notify Medical Director of Dietician Recommendations
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards of practice by not notifying a resident's Medical Director of the Registered Dietician's recommendations in a timely manner. According to the facility's policy, dietician notes and recommendations are to be given to the Director of Nursing (DON) for nursing staff to send to the physician for review and follow-up. In this case, a resident with multiple complex diagnoses, including supraventricular tachycardia, chronic kidney disease, chronic obstructive pulmonary disease, cardiac pacemaker, aphasia following cerebrovascular disease, and chronic atrial fibrillation, was admitted and had specific tube feeding orders in place. On 02/18/2025, the Registered Dietician made recommendations to change the resident's tube feeding formula and add liquid protein supplements. These recommendations were faxed to the Medical Director's office the same day. However, there was no follow-up via telephone after the facility did not receive a response from the Medical Director. The facility did not receive any correspondence regarding the recommendations until 03/05/2025, after the resident had already passed away in the hospital. Interviews confirmed that the process for follow-up was not completed as required by facility policy.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse and neglect, resulting in an Immediate Jeopardy situation. A staff member, identified as a CNA, verbally abused a resident by yelling and using profanity, which caused emotional distress and fear. The resident, who was cognitively intact, reported the incident to the administrator, but the response was inadequate as the staff member was merely reassigned to a different hall without further investigation or action. Additionally, there were incidents of resident-to-resident physical abuse. One resident, who had a history of aggressive behavior, hit another resident in the face with a box of cookies and later pulled another resident's hair. These incidents were not properly addressed or reported as abuse by the facility's administration, indicating a lack of appropriate response to resident altercations and failure to ensure a safe environment for all residents. Furthermore, the facility neglected a resident by failing to adhere to the required two-person assist with a mechanical lift during transfers. A CNA transferred the resident alone, without the necessary equipment, despite the care plan clearly indicating the need for a two-person assist. This neglectful action was not isolated, as other staff members also admitted to transferring residents without assistance due to staffing issues, highlighting systemic neglect in adhering to care protocols.
Removal Plan
- S4 CNA was placed on administrative leave pending thorough investigation.
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- Monitoring tool initiated for S5 CNA Supervisor or designee to complete the lift protocol monitoring tool 4 times a week for 4 weeks, then twice per week for 2 weeks to ensure compliance with lift protocol and mechanical lifts for residents who require 2 person transfer.
- Monitoring tool initiated for every 15 minute and every 30 minute checks for Resident #6, Resident #15, Resident #25, and Resident #51, and shall be turned into S2 DON daily for review.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
- All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
- S6 CNA was in serviced on the policy and procedure for patients requiring mechanical lift.
- Return demonstration for S6 CNA was required. Visual return demonstration was observed by S2 DON.
- Resident #68 was discharged home.
- Interviews were conducted with Resident #15, Resident #6, Resident #25, and Resident #51 to ensure freedom of abuse/neglect. Resident #15 shall continue to be on every 30 minute checks indefinitely. Resident #6 was placed on every 30 minute checks indefinitely. Resident #25 had every 15 minutes checks for 24 hours, then every 30 minute checks indefinitely. Resident #51 was placed on every 30 minute checks for two weeks.
- Resident #25's psychiatrist was informed of resident's behaviors. No new orders were given.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Report Abuse Incidents in a Timely Manner
Penalty
Summary
The facility failed to report several instances of abuse involving both staff-to-resident and resident-to-resident interactions. One incident involved a CNA who verbally abused a resident by yelling and using profanity, which was reported by the resident to the administrator. Despite the resident expressing fear and discomfort, the facility did not report this incident to the State Agency as required. Another incident involved a resident with severe cognitive impairment who physically assaulted two other residents on separate occasions. The first altercation involved the resident hitting another resident in the face with a box of cookies, and the second involved the resident pulling another resident's hair. These incidents were documented in the facility's progress notes, but the facility did not report them to the State Agency, as the Director of Nursing did not perceive them as abuse. The facility's failure to report these incidents in a timely manner, as mandated by state law, resulted in an Immediate Jeopardy situation. The lack of proper reporting and investigation of these abuse allegations has the potential to affect all residents within the facility.
Removal Plan
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- All on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- There was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal, physical, and mental abuse involving three residents. Resident #15, who is cognitively intact, reported an incident where a CNA yelled at her using derogatory language, which caused her emotional distress and fear. Despite Resident #15 reporting the incident to the Administrator, the facility did not consider it an abuse allegation and failed to conduct an investigation or monitor the CNA's behavior. Resident #51 experienced a physical altercation when another resident, Resident #25, hit her in the face with a box of cookies. Although the incident was documented, the Director of Nursing (DON) did not investigate it further, as she was not informed of the physical aspect of the altercation. This lack of investigation left the incident unaddressed, despite the potential for harm. Resident #6, who has severe cognitive impairment, was involved in an incident where Resident #25 pulled her hair. The DON did not perceive this as abuse and did not investigate further, despite a witness reporting the altercation. The facility's failure to recognize and investigate these incidents as abuse resulted in an Immediate Jeopardy situation, as the safety and well-being of the residents were compromised.
Removal Plan
- All current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately.
- There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and Procedure, Lifting protocols, and the facility's Use of Mechanical Lift. In-service included monitoring for a reporting resident to resident abuse, staff to resident abuse, and neglect. In addition, reporting and investigation requirements of all alleged incidents of abuse and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse and neglect.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Failure to Provide Water with Meals
Penalty
Summary
The facility failed to provide drinks consistent with resident preferences and needs, specifically failing to offer water to 10 residents during lunchtime in Hall X dining room. Observations on two consecutive days revealed that staff served lunch trays with only juice and milk, without offering or providing water. Interviews with the S5 CNA Supervisor confirmed that the kitchen did not include water on the meal trays, and water was only provided if specifically requested by a resident.
Deficiency in Abuse and Neglect Reporting and Response
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple instances of abuse and neglect affecting five residents. One resident was subjected to verbal abuse by a CNA, who yelled derogatory remarks, causing emotional distress and fear. Another resident experienced physical abuse from a fellow resident, who hit them with a box of cookies, leading to anger and distress. Additionally, a resident was neglected when a CNA failed to follow the required two-person assist protocol during a transfer, risking physical harm. The facility did not have an effective system in place to ensure that all alleged violations involving abuse and neglect were reported immediately. This failure was evident in the lack of timely reporting of incidents involving verbal and physical abuse, as well as neglect. The facility's administration did not recognize certain incidents as abuse, leading to a lack of investigation and monitoring of the involved staff and residents. This oversight contributed to the continuation of abusive and neglectful situations within the facility. Interviews with the facility's administration revealed a lack of awareness and understanding of the incidents as abuse or neglect. The Director of Nursing and Administrator did not consider certain incidents as reportable, resulting in a failure to investigate and report them to the State Agency. This deficiency in recognizing and addressing abuse and neglect compromised the safety and well-being of the residents, highlighting significant gaps in the facility's policies and procedures for handling such incidents.
Removal Plan
- In-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect.
- S4 CNA was placed on administrative leave pending thorough investigation.
- S6 CNA was in services on proper lifting techniques with proper return demonstration completed.
- S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30 days, then 3 times weekly for 2 weeks to ensure compliance is sustained.
- Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days.
- There was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift.
- A monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately.
- The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months.
Inconsistent Documentation of Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was properly documented in their medical record. Specifically, there was inconsistency in the documentation of the resident's code status. The resident, who had a history of cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, was listed as a Full Code in the electronic record dashboard/orders, while the physician's orders and care plan indicated a DNR (Do Not Resuscitate) status. Interviews with facility staff revealed that the staff relied on the electronic record dashboard/orders to determine a resident's advance directive during a code. The Director of Nursing confirmed the inconsistency in the resident's electronic record and care plan regarding the advance directive and acknowledged that the records should have been updated to reflect the correct DNR status, but they were not.
Failure to Complete PASARR Level II Screening for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder had an accurately completed PASARR Level II screening. The deficiency was identified for a resident who was admitted with a Level I PASARR screening, which indicated no need for a Level II screening due to the absence of a mental illness diagnosis at the time of admission. However, after admission, the resident was diagnosed with Bipolar Disorder, which should have triggered a Level II screening according to the facility's PASARR policy. The deficiency was confirmed through a review of the resident's medical records and an interview with the Director of Nursing (DON). The records showed that the resident was diagnosed with Bipolar Disorder after admission, and a psychiatric evaluation indicated persistent symptoms of depression and delusions. Despite these developments, the required Level II screening was not completed, as confirmed by the DON during the interview.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #34, who has a history of falls and requires a fall mat as per physician's orders, was observed multiple times without the fall mat in place. Despite the care plan and physician's orders specifying the need for a fall mat, it was not present at the bedside, as confirmed by both the LPN and the DON. Resident #36, who also has a history of falls and requires a fall mat, was observed with the fall mat propped against the wall instead of being placed on the floor beside the bed. This improper placement of the fall mat was confirmed by the DON, who acknowledged that the mat should have been on the floor to prevent falls. Resident #37, who requires two-person assistance for bed mobility and toileting, experienced a fall when a CNA attempted to provide care alone. The care plan clearly indicated the need for two-person assistance, but this was not followed, resulting in the resident rolling out of bed during incontinent care. The DON confirmed that the CNA did not adhere to the care plan, leading to the incident.
Failure in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a Stage 3 pressure ulcer on the sacral region. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, dysphagia, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had specific physician orders for wound care. These orders included cleaning the ulcer with a wound cleanser, applying Santyl, and using a collagen dressing covered with a silicone bordered foam dressing, to be changed daily or as needed. However, during an observation of wound care, the treatment nurse placed clean gloves on an unclean bedside table, which was on top of the resident's belongings, before using them for wound care. This action contaminated the gloves, which were then used to clean the wound. Additionally, the treatment nurse failed to follow proper infection control procedures by not removing soiled gloves and sanitizing hands before obtaining new supplies from the clean field and continuing with the wound care. This lapse in protocol was confirmed during an interview with the treatment nurse, who acknowledged the findings. The failure to adhere to professional standards of practice in wound care compromised the resident's treatment and potentially increased the risk of infection.
Failure to Administer Enteral Flush as Ordered
Penalty
Summary
The facility failed to administer a resident's enteral flush according to the physician's orders. The resident, who was admitted with conditions including cerebrovascular disease, dysphagia following cerebral infarction, generalized anxiety disorder, bipolar disorder, and chronic systolic heart failure, had a physician's order for Glucerna 1.5 cal at 60cc/hour with 35cc/hour water flushes per pump. However, observations on two consecutive days revealed that the resident's water flush was set at 30cc/hour instead of the prescribed 35cc/hour. An interview with the Assistant Director of Nursing confirmed that the water flush was incorrectly set, deviating from the physician's orders.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident by not administering oxygen as ordered by the physician. The resident, who was admitted with diagnoses including cerebrovascular disease, shortness of breath, and severe cognitive impairment, was dependent on staff for activities of daily living and required continuous oxygen therapy. The physician's order specified oxygen at 2 liters per minute via nasal cannula, but observations on two consecutive days revealed the oxygen was set at 3 liters per minute. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen settings were not in accordance with the physician's order. The LPN acknowledged that the oxygen concentrator was set incorrectly and should have been at 2 liters per minute. The Director of Nursing also confirmed that a physician's order is required to adjust oxygen settings, indicating a failure to adhere to the prescribed care plan for the resident.
Failure to Maintain Accurate Narcotic Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of drugs to meet the needs of each resident. During an observation, it was noted that the narcotic log for a resident's Gabapentin 300mg capsules showed 18 capsules documented, but the blister pack contained only 17 capsules. Similarly, the narcotic log for the same resident's Morphine 30mg tablets showed 2 tablets documented, while the blister pack contained only 1 tablet. The LPN responsible for administering these medications admitted to not signing out the medications on the narcotic record log sheet after administration. Another resident's narcotic record log for Gabapentin 300mg capsules showed 44 capsules documented, but the blister pack contained 43 capsules. The LPN confirmed that she failed to update the narcotic record log sheet with the correct amount remaining in the medication packs after administering the medications. The Director of Nursing confirmed that all controlled medications should be signed off on the narcotic record log sheet immediately after administration by the nurse.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of needs, specifically regarding the placement of a call bell. The deficiency was identified for a resident who had a history of cerebral infarction, CVA, seizure disorder, and hypertension, and was cognitively impaired with a BIMS score of 8. The resident was dependent on staff for activities of daily living, including oral hygiene, showering, bathing, and dressing. Despite the facility's policy requiring call bells to be within reach, observations on multiple occasions revealed the call bell was draped over a plug-in receptacle box on the wall behind the resident, making it inaccessible. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident was capable of using the call bell to request assistance. However, the call bell was repeatedly found out of reach during observations. The LPN confirmed the call bell's inaccessibility and subsequently placed it within reach, allowing the resident to activate it. The facility's failure to ensure the call bell was consistently within reach of the resident constituted a deficiency in accommodating the resident's needs.
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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