St Jude's Health & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 450a S Claiborne Ave, Fl 6, New Orleans, Louisiana 70112
- CMS Provider Number
- 195517
- Inspections on file
- 28
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 16 (2 serious)
Citation history
Health deficiencies cited at St Jude's Health & Wellness Center during CMS and state inspections, most recent first.
An LPN physically and verbally abused a resident who was moderately cognitively intact, repeatedly striking the resident’s face, head, shoulders, arms, and chin, kneeling on the resident’s neck, attempting to drag the resident by his shirt across the floor, and yelling profanities such as “b***h, don’t hit me” and “b***h, I’m tired of you” in the presence of staff and another cognitively intact resident. Two CNAs witnessed the abuse, briefly intervened to pull the LPN off when it appeared the resident could not breathe, but did not immediately report the incident to the Administrator or ensure the LPN was removed from resident contact; instead, they left the unit for several minutes to seek assistance, leaving the LPN alone with the abused resident and about 20 other residents, and later only intermittently monitored the situation while completing rounds. The Administrator and DON later acknowledged that the LPN should not have been left alone with residents after the abuse and that the abuse should not have occurred.
The facility failed to ensure that witnessed physical and verbal abuse of a resident by an LPN was reported to the administrator and state agency within the required 2-hour timeframe. An LPN repeatedly struck a resident’s face, head, and shoulders with a closed fist, placed her knee on the resident’s neck, attempted to drag the resident by his shirt, and yelled profanities at the resident in front of staff and another resident. The LPN also directed CNAs not to assist the resident from the floor or from his chair, and the CNAs left the unit for several minutes and later left the LPN unmonitored with access to all residents. Despite facility policies requiring immediate reporting of suspected or actual abuse, the CNAs who witnessed or were informed of the abuse did not notify administrative staff until the following day, and the administrator acknowledged the incident was not reported to the state agency within the mandated timeframe.
A cognitively intact resident, identified on the facility’s smoker list as an unsafe smoker, was denied the ability to smoke during nighttime hours because they were not on the facility’s safe smoker list, despite a policy stating residents have the right to smoke and that cognitively impaired or mobility-limited residents may smoke with staff supervision. The resident reported being refused nighttime smoking, an LPN confirmed the resident was not on the list allowing smoking after extended hours, and reception staff stated that unsafe smokers were not permitted to go outside at night and acknowledged they had previously denied this resident’s requests to smoke during those hours, contrary to the DON’s description of how unsafe smokers should be supervised.
A resident with moderate cognitive impairment was found with medications left unsecured at the bedside, contrary to the facility’s medication storage policy requiring locked compartments and restricted access to drugs. Surveyors observed a split white pill on the floor next to a labeled medication cup and another labeled cup containing a pill on the bedside table. An LPN confirmed the medications had been left in the room, acknowledged the resident did not have the capacity to self-administer medications, and stated they should not have been left at the bedside; the DON also acknowledged that the medications were improperly left in unlocked, unattended cups.
A resident with stage 4 CKD had a physician-ordered renal diet specifying no potatoes, which was reflected on the meal ticket. However, the resident was observed being served cubed potatoes. An LPN acknowledged this conflicted with the renal diet, and the DON explained that the process requires dietary staff to follow the meal ticket and floor staff to verify trays against diet orders, confirming the resident should not have received potatoes.
Staff failed to follow hand hygiene and glove-change requirements during incontinence care for a resident. Two CNAs removed a soiled brief, cleansed the buttocks and perineal area, and then proceeded to apply a clean brief, reposition the resident, place a clean draw sheet, and handle clean linens and room furnishings without changing gloves or performing hand hygiene, despite facility policy and CDC guidelines requiring hand decontamination when moving from contaminated to clean body sites. Both CNAs later acknowledged they should have changed gloves and performed hand hygiene, and the DON confirmed this expectation.
The facility did not administer influenza and pneumococcal vaccines to a resident despite signed consents from the responsible party and a facility policy requiring vaccination unless contraindicated or refused. The resident, who had moderately impaired cognition, expressed a desire to receive both vaccines, and the responsible party confirmed consent had been given. Review of the clinical record showed no documentation of vaccine administration, and the ADON/Infection Preventionist, DON, and Administrator all acknowledged there was no evidence the vaccines had been provided.
A resident was physically struck in the face by another resident in the day room, with the incident witnessed by two CNAs and later confirmed by those involved. The facility's investigation substantiated that resident-to-resident abuse occurred, reflecting a failure to protect residents from physical mistreatment as required by policy.
A resident in an LTC facility was hospitalized with valproic acid toxicity after the facility failed to conduct a timely lab test as ordered by the resident's nurse practitioner. The resident, on Depakote for dementia and anxiety, showed signs of lethargy and unresponsiveness, leading to their transfer to the hospital. The facility's DON acknowledged the oversight, and the consulting pharmacist highlighted the importance of monitoring valproic acid levels.
A resident was hospitalized with valproic acid toxicity after the facility failed to implement a physician's lab order for a valproic acid level. The DON was responsible for ensuring lab orders were carried out but could not explain the oversight. The COO identified problems from grievances and surveys, but the deficiency was not addressed in time. The CEO did not initially recognize the situation as Immediate Jeopardy, and no additional documentation was provided to dispute the findings.
A facility failed to maintain a safe and clean environment for a resident, as maintenance did not cover a wall socket and housekeeping did not clean an unknown brown substance from the floor. These issues were confirmed by the COO during observations.
A facility failed to provide timely incontinence care for a resident who required substantial assistance for toileting and personal hygiene. The resident was found with a bowel movement leaking from the adult brief onto the abdomen, incontinent pad, and bed sheets, indicating a lapse in care. The CNA last checked the resident at 3 AM, not adhering to the 2-hour check requirement. The DON confirmed the resident should be checked every 2 hours.
A facility failed to ensure staff used proper PPE for a resident on EBP. A CNA entered a resident's room without a gown and emptied the urinary catheter, contrary to policy. The CNA was unaware of the requirement, and both the DON and Infection Preventionist confirmed the need for gowns during such procedures.
The facility restricted resident visitation to between 8:00 AM and 8:00 PM, requiring exceptions to be approved by the Administrator or DON, without documented clinical or safety reasons. Interviews with a resident and staff confirmed the enforcement of these restricted hours, despite the Administrator's acknowledgment that residents should have unrestricted visitation.
A facility failed to provide adequate dialysis care for a resident by not assessing the dialysis access site or obtaining vital signs upon return from dialysis. There was also a lack of communication with the dialysis center regarding the resident's condition. Interviews confirmed these deficiencies, with staff acknowledging the failure to follow the facility's process for dialysis care documentation.
The facility failed to properly label and dispose of insulin pens, resulting in a deficiency. An observation of a medication cart revealed that several insulin pens were either not labeled with the date they were opened or were available for use beyond the recommended period. An LPN and the DON confirmed that the facility's policy required insulin to be discarded 28 days after opening, and the medications in question had been opened over 30 days ago.
A resident's right to smoke was restricted by the facility's policy, which only allowed smoking between 7:00AM and 7:00PM. Despite being identified as a safe smoker and cognitively intact, the resident was not permitted to smoke outside these hours, as confirmed by interviews with staff, including the Smoking Aide and Administrator.
A facility failed to ensure a resident's code status was consistent across medical records. The resident's chart indicated a Full Code status, while the EMR and physician's orders showed a DNR status. Interviews with an LPN and the DON confirmed the discrepancy, which could lead to inappropriate medical interventions.
The facility failed to provide and explain the required Medicare Non-Coverage Notices to three residents before terminating their Medicare Part A services. The NOMNC forms were not documented as given or signed, and the SNFABN forms were signed without explanation. One resident had severe cognitive impairment, highlighting the need for proper communication with responsible parties.
The facility failed to accurately assess the dental status of two residents upon admission. One resident with moderate cognitive impairment and another with intact cognition were both reported to have no dental issues, despite observations and interviews confirming missing teeth. The facility administrator could not explain the discrepancies in the MDS assessments.
A facility failed to maintain a resident's Level II PASARR documentation in their medical record. The resident, admitted with Schizophrenia, Bipolar Disorder, and Unspecified Dementia, lacked the necessary documentation completed by the Office of Behavioral Health. Staff acknowledged the oversight during interviews.
A facility failed to supervise a resident identified as an unsafe smoker. The resident, with severe cognitive impairment and listed on the Unsafe Smoker List, was observed smoking without direct supervision. The smoking aide was seated away from the resident, who received a cigarette and had it lit by other residents. Staff confirmed the need for direct supervision, which was not provided, leading to a deficiency in care.
A facility failed to limit a resident's PRN order for Lorazepam, a psychotropic medication, to 14 days or provide a clinical rationale for its continuation. The order lacked documentation of a specified duration or physician's rationale, as acknowledged by the DON.
A resident's CBC was not completed as ordered due to the lab's inability to obtain a specimen, and the physician was not notified. The facility lacked documentation of the physician's notification, as confirmed by the DON.
Two residents in the facility were not provided with necessary dental services, despite both expressing a desire to see a dentist and obtain dentures. Observations revealed that both residents were missing several teeth, and there was no documented evidence of dental evaluations since their admission. The facility's dental treatment schedule did not include these residents, and interviews with staff confirmed the lack of evaluation without providing a reason.
The facility's dumpster was observed to be missing a lid and open to the air, with loose trash on the ground around it. The Dietary Manager and Administrator acknowledged the issue, confirming that the dumpster and its surrounding area were not maintained in a sanitary manner.
The facility did not involve direct care staff, residents, or their representatives in the development of its facility-wide assessment. There was no documented evidence of participation from an LPN, a CNA, a resident, or a resident representative, as confirmed by the administrator.
The facility failed to administer the pneumococcal vaccine to two residents who had signed consents for the vaccination. Despite the consents, there was no documented evidence that the vaccines were administered or medically contraindicated. Interviews with the administrator confirmed the lack of documentation, highlighting a deficiency in the facility's vaccination process.
The facility failed to administer the COVID-19 vaccine to a resident despite having obtained consent from the responsible party. There was no documentation to indicate that the vaccine was given or that it was medically contraindicated. The administrator confirmed the absence of such documentation.
The facility failed to implement and review individualized fall prevention interventions for three residents who experienced multiple falls. Despite policies requiring new interventions after each fall, there was no documented evidence of these interventions being implemented or reviewed for effectiveness. Interviews with staff confirmed the lack of documentation and communication regarding updates to the residents' care plans.
The facility failed to maintain a sanitary environment for two residents. One resident's room had a brown smear on the wall, while another resident's room and bathroom were found with multiple unsanitary conditions, including a dirty isolation cart, brown substances on surfaces, and cluttered bedside tables. Interviews with staff confirmed these conditions, and the resident expressed dissatisfaction with the cleanliness.
A resident in an LTC facility was found with a dislocated hip, but the facility failed to conduct a thorough investigation. The investigation lacked statements from all relevant staff, including LPNs and CNAs who observed the resident's condition. The Director of Nursing and Administrator did not obtain comprehensive documentation, leading to an incomplete understanding of the incident.
A resident with severely impaired cognition experienced a decline in ADLs and multiple falls, including a hip fracture from a wheelchair fall. The facility failed to update the care plan to address these changes, as confirmed by the administrator.
A CNA was observed asleep while on duty, failing to provide care to seven residents during a day shift. The CNA had signed the facility's Employee Code of Conduct, which prohibits sleeping on duty. The incident was confirmed by the DON and the facility's Administrator.
The facility failed to ensure that nurse aides were trained and competent, allowing uncertified staff to work independently and provide direct care to residents. This deficiency was identified for eight staff members, including direct service workers and a front desk receptionist, who were not enrolled in or scheduled for any CNA certification courses. The facility's policy required qualified nursing staff, but uncertified staff were assigned to work independently, putting all 79 residents at risk.
The facility failed to ensure that staff working as nurse aides met the minimum state-approved competency and training requirements. This resulted in an Immediate Jeopardy situation when unqualified staff were allowed to work independently, providing direct care to residents without the necessary certification or training. The deficiency was confirmed through observations, interviews, and record reviews.
Failure to Protect Resident From Physical and Verbal Abuse and to Immediately Remove Abusive LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a staff member and to immediately remove the alleged perpetrator from resident contact after the abuse was witnessed. On the date of the incident at approximately 4:00 PM, an LPN physically and verbally abused a resident identified as moderately cognitively intact, with a BIMS score of 12 on a recent MDS. The LPN hit the resident repeatedly on the face, head, shoulders, arms, and chin area with a closed fist, placed her knee on the resident’s neck to pin him down, grasped his shirt and attempted to drag him across the floor, and yelled profanities at him, including “b***h, don’t hit me,” “b***h, don’t touch me,” “b***h I’m tired of you,” and “b***h get off of me.” This conduct was directly witnessed by two CNAs and another resident, who was cognitively intact with a BIMS score of 15. During the incident, one CNA intervened by getting the resident to release the LPN and give her his hands, after which the LPN initially got up as if to walk away, then turned back, put her knee on the resident’s neck, and continued to strike him. The CNAs reported that it appeared the resident could not breathe with the LPN kneeling on his neck, prompting them to pull the LPN off the resident. The LPN then walked away, returned, and again attempted to drag the resident by his shirt on the floor. Throughout this time, the LPN continued to verbally abuse the resident and instructed the CNAs, in the resident’s presence, to “leave that b***h on the floor, don’t help him up.” Later, around 5:00 PM, when one CNA was preparing to make rounds, the LPN again verbally abused the resident by instructing the CNA, in front of the resident, to “leave that b***h in his chair.” The resident later stated in an interview that the LPN had previously hit him. Despite witnessing the physical and verbal abuse, the CNAs did not immediately report the incident to the Administrator or remove the LPN from resident contact. Instead, both CNAs left the floor for approximately eight minutes to find assistance to get the resident off the floor, leaving the LPN alone with the abused resident and approximately 20 other residents on that floor. One CNA stated she was in shock and did not know what to do, and the other CNA indicated that at the time of the incident she did not know who to report abuse to. During the period from approximately 5:00 PM to 6:00 PM, one CNA only periodically visualized the resident and the LPN while completing rounds and did not constantly monitor them, leaving the LPN with ongoing access to the resident and other residents. Facility leadership, including the Administrator and DON, later acknowledged that the LPN should not have been left alone with residents after the abuse occurred and that the physical and verbal abuse should not have happened.
Removal Plan
- S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.
- S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.
- S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement.
- Staff performed an assessment of Resident #1 for any injuries and/or pain.
- S1Administrator entered a report regarding the physical and verbal abuse in the State Incident Management System (SIMS).
- Resident #1's medical provider conducted a psychological evaluation on Resident #1.
- S1Administrator had staff do an audit of the other residents that resided on Floor b to determine if they have suffered any abuse.
- S1Administrator obtained a witness statement from Resident #2.
- S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator.
- S1Administrator reported the physical and verbal abuse to the local police department.
- S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners.
Failure to Timely Report Witnessed Physical and Verbal Abuse by an LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that witnessed physical and verbal abuse of a resident was reported to the administrator/designee and the state agency within the required 2-hour timeframe. On 02/17/2026 at approximately 4:00 PM, an LPN physically and verbally abused Resident #1 by repeatedly hitting him on the face, head, and shoulders with a closed fist, placing her knee on his neck, grasping his shirt and attempting to drag him across the floor, and yelling profanities at him, including, “b***h, don’t hit me” and “b***h, I’m tired of you.” This abuse was witnessed by two CNAs (S5 and S6) and another resident (Resident #2). The LPN further stated to the two CNAs, in front of Resident #1, “leave that b***h on the floor, don’t help him up.” The immediate jeopardy situation continued when the two CNAs left Floor B for approximately 8 minutes, leaving Resident #1 and 20 other residents alone on the unit with the same LPN who had just committed the physical and verbal abuse. Later, at approximately 5:00 PM, the LPN instructed one of the CNAs, again in front of Resident #1, to “leave that b***h in his chair.” The CNA then left the LPN unmonitored and with access to all 21 residents on Floor B while she went in and out of rooms to complete her rounds. Despite witnessing the abuse and understanding that abuse should be reported immediately, the CNAs did not report the incident to the administrator or other administrative staff within 2 hours, and the LPN remained on duty until she clocked out at 11:20 PM. Multiple staff interviews confirmed that the abuse was not reported in a timely manner and that there was confusion or lack of knowledge among some staff about how to contact administrative staff when they were not physically present in the facility. S5CNA acknowledged she did not report the abuse to any administrative staff or nurses until the morning of 02/18/2026 and stated she did not know how to reach them at the time of the incident. S6CNA similarly indicated that the abuse should have been reported immediately but was not reported until the next day, and that she did not know who to report to at the time. Another CNA (S7) reported that S5CNA told her about the abuse on 02/17/2026, but she also did not report it, despite having the phone numbers of the administrator and DON. The administrator and DON both indicated that the CNAs who witnessed or knew of the abuse should have reported it immediately. The administrator acknowledged that the physical and verbal abuse should have been reported to the state agency within 2 hours, which did not occur. The facility’s abuse-related policies, including the Abuse Prevention policy, Abuse Recognition, Reporting, and Investigation policy, and Abuse Reporting and Investigation policy, required that any person who witnessed or suspected abuse immediately inform the house supervisor, who would notify the administrator or designee, and that the administrator or designee report all allegations of suspected or actual abuse through the state incident reporting system and to proper parties as required by state and federal law. Despite these policies, the witnessed abuse of Resident #1 by the LPN on 02/17/2026 was not reported to the administrator until approximately 10:30 AM on 02/18/2026, and thus was not reported to the state agency within the required 2-hour timeframe. This failure to follow established reporting procedures and to promptly notify the appropriate authorities constituted the cited deficiency.
Removal Plan
- S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.
- S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.
- S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement.
- S1Administrator had staff perform an assessment of Resident #1 for any injuries and/or pain.
- S1Administrator entered a report regarding the physical and verbal abuse in the State Incident Management System (SIMS).
- Resident #1's medical provider conducted a psychological evaluation on Resident #1.
- S1Administrator had staff do an audit of the other residents that resided on Floor b to determine if they have suffered any abuse.
- S1Administrator obtained a witness statement from Resident #2.
- S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator.
- S1Administrator reported the physical and verbal abuse to the local police department.
- S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners.
Failure to Honor Resident’s Right to Smoke per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to smoke in accordance with its own Resident Smoking and Tobacco Use Policy. The policy, effective 08/01/2025, stated that residents had the right to smoke, and that residents who were cognitively impaired or had mobility limitations could only smoke under staff supervision, with staff responsible for monitoring compliance. Resident #6’s Quarterly Minimum Data Set dated 12/26/2025 showed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Despite this, the facility’s undated list of smokers identified Resident #6 as an unsafe smoker. Resident #6 reported on 01/22/2026 that he was not allowed to go outside to smoke at night because he was not on the list permitting smoking after 7:00 PM. An LPN confirmed that Resident #6 was not on the list of smokers allowed to smoke past the extended hours of 7:00 AM to 8:00 PM. The DON stated that the security guard, evening receptionist, and/or night receptionist were responsible for supervising unsafe smokers who wanted to smoke outside the 7:00 AM to 7:00 PM timeframe. However, two receptionists reported that unsafe smokers were not allowed to go outside to smoke at night and that only residents on the safe smoker list could go out during those hours. Both receptionists acknowledged they had previously refused Resident #6 the ability to smoke at night because he was not on the safe smoker list, resulting in the resident being denied the right to smoke during nighttime hours.
Medications Left Unsecured at Bedside of Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that medications were stored in locked compartments and accessible only to authorized personnel, resulting in a resident having medications left at the bedside. The facility’s undated Storage of Medications policy stated that medications were to be stored in locked compartments, in their original packaging, and that only persons authorized to prepare and administer medications should have access to them. Review of a quarterly MDS for Resident #47, with an Assessment Reference Date of 10/29/2025, showed a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. During observation of Resident #47’s room on 01/21/2026 at 12:40 PM, surveyors noted a white pill on the floor split in two next to a medication cup labeled with Resident #47’s name, and a second medication cup, also labeled with the resident’s name, containing a white pill on the bedside table. In interviews, the LPN confirmed the pills and medication cups were in the resident’s room, stated that the medications should not have been left at the bedside, and reported that the resident did not have the mental capacity to self-administer medications; the DON also acknowledged that the medications should not have been left at the bedside in unlocked, unattended medication cups. These observations and interviews demonstrate that the facility did not follow its own medication storage policy and allowed a moderately cognitively impaired resident unsupervised access to medications in the room, contrary to requirements that only authorized staff have access to drugs and biologicals and that such items be stored in locked compartments.
Failure to Follow Renal Diet Restrictions for Resident with CKD
Penalty
Summary
The facility failed to provide a diet that met a resident's special dietary needs when a resident with a physician-ordered renal diet was served food inconsistent with that order. The facility's undated Nutrition policy stated that all physician-ordered diets were to be implemented promptly and that the dietary department was to prepare and serve meals that met ordered diets and nutritional requirements. The resident's medical record showed a diagnosis of stage 4 chronic kidney disease, and the January 2026 physician's orders specified a renal diet. The resident's meal ticket for 01/21/2026 further specified a renal diet with no potatoes. Despite these orders and documentation, observation on 01/21/2026 at 1:05 PM showed the resident was served cubed potatoes. An LPN immediately acknowledged that the resident should not have been served potatoes per the renal diet. The DON described the facility's process for ensuring correct diets, stating that diet recommendations are placed on the meal ticket, dietary aides are to follow the meal ticket when preparing plates, and floor staff are to check trays against the meal ticket when distributing them, notifying nursing and dietary if inconsistencies are found. The DON confirmed that the resident should not have been served potatoes.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during incontinence care. The facility’s Standard Precautions policy required staff to perform hand hygiene immediately after contact with any resident item that may be contaminated, and CDC guidelines required hand decontamination when moving from a contaminated body site to a clean body site during patient care. During an observation, two CNAs entered a resident’s room to perform incontinence care, removed the resident’s soiled diaper, and wiped the resident’s buttocks and perineal area. After completing care of the contaminated area, the CNAs did not change their gloves or perform hand hygiene before proceeding to place a clean diaper on the resident, roll and reposition the resident, place a clean draw sheet, and cover the resident with clean linen. One CNA then opened and closed the resident’s dresser door and raised the head of the bed while still wearing the contaminated gloves, without performing hand hygiene or changing gloves. In subsequent interviews, both CNAs acknowledged they had not changed gloves or performed hand hygiene after removing the soiled diaper and stated they should have done so. The DON confirmed that the CNAs should have changed gloves and performed hand hygiene when moving from a contaminated body area to a clean body area during incontinence care.
Failure to Administer Influenza and Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were administered in accordance with its own policy for one resident. The facility’s undated Influenza and Pneumococcal Vaccine policy stated that residents should be vaccinated against pneumococcal disease and influenza unless medically contraindicated or refused by the resident or legal representative. Resident #60’s Minimum Data Set, with an Assessment Reference Date of 01/07/2026, showed the resident was admitted on 07/02/2025 and had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. Review of the clinical record on 01/20/2026 revealed no documented evidence that the resident had received either the influenza or pneumococcal vaccines. Further record review showed that on 07/02/2025, the resident’s responsible party had signed consent forms for both the pneumococcal and influenza vaccines. In an interview, the resident stated he wanted the influenza and pneumococcal vaccines but had not received them, and the responsible party confirmed she had consented for the vaccines and was unsure if they had been given. The Assistant DON/Infection Preventionist reported that the facility had no evidence the resident received either vaccine since admission. The DON and the Administrator both acknowledged in interviews that the resident had not received the influenza or pneumococcal vaccinations prior to 01/21/2026 and that the resident should have received them.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its own Abuse Recognition, Reporting, and Investigation policy. On the morning of 09/10/2025, one resident entered the day room and struck another resident in the face, an incident witnessed by two CNAs. The physical altercation was later confirmed by both the resident who committed the act and the staff who observed it. The facility's investigation substantiated that resident-to-resident abuse had occurred, indicating a failure to prevent physical mistreatment as outlined in facility policy.
Failure to Conduct Timely Lab Test Leads to Hospitalization
Penalty
Summary
The facility failed to obtain timely laboratory services as per physician's orders for a resident, leading to an Immediate Jeopardy situation. The resident, who had been prescribed Depakote for dementia and anxiety disorder, required a valproic acid level test ordered by their nurse practitioner. However, the test was not conducted, resulting in the resident being hospitalized with valproic acid toxicity. The resident was admitted to the hospital after being observed as lethargic and unresponsive, with a valproic acid level significantly above the normal range. The facility's Director of Nursing (DON) acknowledged that routine labs were scheduled for specific days, but there was no documented evidence that the lab order was executed. The consulting pharmacist emphasized the importance of monitoring valproic acid levels due to the risk of toxicity. Interviews with facility staff revealed a lack of explanation for the failure to conduct the test. The Chief Operating Officer (COO) and DON were informed of the Immediate Jeopardy, and the COO was responsible for quality improvement efforts. Despite the CEO's disagreement with the Immediate Jeopardy classification, no additional evidence was provided to dispute the findings.
Removal Plan
- A daily audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
- Education will include the physician and their extenders, clinical managers, and facility nurses. Nurses will receive this in-service prior to their next scheduled shift.
- Education started immediately.
- Daily monitoring will begin of any lab orders, old or new, making sure the order has been accurately and successfully carried out and that the results have been communicated to the medical doctor or nurse practitioner office.
- The Director of Nursing or her designee will review lab orders in point click care, lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
- Daily review of labs will continue for one month after such time this will be reviewed weekly in the high-risk meeting.
- Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
- Lab orders will be added as one of the agenda items to be discussed during morning stand up meeting.
Failure to Implement Physician Lab Orders Leads to Resident Hospitalization
Penalty
Summary
The facility's administrative staff failed to effectively oversee the implementation of physician laboratory orders, resulting in a deficiency. Specifically, the facility did not ensure that a valproic acid level was drawn for a resident after it was ordered by the resident's nurse practitioner. This oversight led to the resident being hospitalized with valproic acid toxicity, a condition that can lead to severe health consequences. Interviews and record reviews revealed that the Director of Nursing (DON) was responsible for ensuring laboratory orders were carried out. However, there was no documented evidence that the laboratory services were performed as ordered. The DON indicated that after a lab order is placed, it is given to the floor nurse to enter into the computer, but could not explain why the valproic acid level was not drawn for the resident. The Chief Operating Officer (COO) was in charge of quality and identified problems from grievances and surveys, but the deficiency was not addressed in time to prevent the resident's hospitalization. The Chief Executive Officer (CEO) did not initially recognize the situation as an Immediate Jeopardy, and no additional communication or documentation was provided to dispute the findings. This lack of administrative oversight had the potential to affect all residents with medications requiring lab orders.
Removal Plan
- The facility planned to improve communication between nursing, pharmacy consult, and medical doctors and put more oversight by leadership of the laboratory process.
- A daily audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
- S6Chief Executive Officer (CEO) or his designee will do a visual check to ensure the audits have occurred.
- S6CEO or his designee will attend one high risk meeting to verify lab orders are being reviewed.
- Education will include the physician and extenders, clinical managers, and facility nurses. A daily review will be completed by S2DON or her designee to ensure nothing is missed or not followed up on timely.
- S6CEO or his designee will verify education has been completed as stated through a visual review of the sign in sheets.
- All staff nurses will be in-serviced on the lab order protocol.
- S6CEO/his designee began providing administrative staff with the same education that is being provided to the nurses.
- All administrative staff at the facility will be in-serviced.
- Daily monitoring began of any lab orders, old or new.
- Verification that the order has been accurately and successfully been carried out and that the results have been communicated to the medical doctor or nurse practitioner office. These audits are to be done by S2DON or her designee.
- S2DON or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
- S6CEO or his designee will verify the audits and will participate in one high risk meeting to verify compliance.
- Daily review of labs began and will continue after such time this will be reviewed in the high-risk meeting.
- Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
- Lab orders will be added as an agenda item in the daily, weekday, stand-up meeting.
- S6CEO or his designee will attend one stand up meeting to ensure the agenda remains unchanged.
Facility Fails to Maintain Safe and Clean Environment for Resident
Penalty
Summary
The facility failed to ensure a safe and clean environment for a resident, as evidenced by two specific deficiencies. Firstly, maintenance services did not place an outlet cover over a wall socket in the resident's room, which was observed on two separate occasions. Secondly, housekeeping services failed to clean an unknown brown substance off the floor near the resident's bed, which was also noted during both observations. These issues were confirmed by the Chief Operating Officer, who acknowledged the absence of the outlet cover and the presence of the substance on the floor.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care for Resident #1, who required substantial/maximal assistance for toileting and personal hygiene. According to the Minimum Data Set with an assessment reference date of 01/24/2025, Resident #1 was incontinent of bowel and bladder, and the care plan included an intervention to check the resident every 2 hours for incontinence. However, on 03/10/2025 at 6:32 AM, an observation revealed that Resident #1 had a bowel movement leaking from the adult brief onto her abdomen, incontinent pad, and bed sheets, indicating that the incontinence care was not provided as required. The bowel movement was wet in the center and dry around the edges, suggesting it had been there for some time. In an interview, S4CNA stated that the last time Resident #1 was checked and changed was around 3 AM, which was not in compliance with the 2-hour check requirement. S2Director of Nursing confirmed that Resident #1 should be checked every 2 hours for incontinence.
Failure to Use Proper PPE During EBP
Penalty
Summary
The facility failed to ensure that staff utilized the correct personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). Specifically, a Certified Nursing Assistant (CNA) entered the room of a resident on EBP without wearing a gown and proceeded to empty the resident's urinary catheter, contrary to the facility's policy which requires gowns and gloves to be worn during such procedures. The CNA admitted to not using a gown and was unaware of the requirement. The Director of Nursing and the Infection Preventionist both confirmed that gowns should be worn when emptying urinary catheters for residents on EBP.
Facility Restricts Resident Visitation Hours
Penalty
Summary
The facility failed to honor residents' rights to receive visitors of their choosing at any time, as required by regulations. The facility's visitation policy, which was undated, encouraged visits only between 8:00 AM and 8:00 PM, with any exceptions requiring approval from the Administrator or Director of Nursing. There was no documented evidence that these visitation restrictions were based on clinical or safety concerns. Interviews with a resident and staff members, including a receptionist and a CNA, confirmed that visitors were not allowed outside of these hours, and no exceptions were made. The Administrator acknowledged that residents should be allowed unrestricted visitation, indicating a discrepancy between the policy and the facility's practice.
Failure to Provide Adequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as Resident #32, who required dialysis services. The deficiencies included the lack of assessment of the resident's dialysis access site and failure to obtain vital signs upon the resident's return from dialysis. The facility's records showed multiple instances where there was no documented evidence of these assessments and vital sign checks on various dates from December 2024 to January 2025. Additionally, there was a lack of communication with the dialysis center regarding the resident's condition on several occasions. Interviews conducted with the resident and facility staff confirmed these deficiencies. The resident reported that the facility staff did not check his dialysis access site upon his return from the dialysis center. An LPN admitted to not obtaining the resident's vital signs after dialysis on a specific date, and the DON acknowledged that the facility's process required staff to assess the dialysis access site and document vital signs on the dialysis communication sheets. These failures were identified as part of the facility's deficient practices in providing dialysis care.
Improper Labeling and Disposal of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin pens, leading to a deficiency in medication management. During an observation of Medication Cart A, it was found that several insulin pens belonging to different residents were either not labeled with the date they were opened or were available for use beyond the recommended 28 to 30 days after opening. Specifically, Resident #10's Humulin R insulin pen, Resident #36's Humulin R and Lantus insulin pens, and Resident #40's Novolog and Humulin insulin pens were all found to be improperly labeled or expired. Interviews with the LPN and the Director of Nursing confirmed that the facility's policy required insulin to be discarded 28 days after opening and that the medications in question had been opened over 30 days ago.
Resident's Right to Smoke Restricted by Facility's Policy
Penalty
Summary
The facility failed to uphold a resident's right to make choices regarding smoking, specifically for Resident #32, who was identified as a safe smoker. The facility's Resident Rights policy indicated that residents should be encouraged to exercise their rights, including the use of tobacco in accordance with applicable policies. However, the facility's Smoking policy restricted smoking to designated areas outside the building, with no documented evidence of agreed-upon smoking hours. Despite Resident #32's cognitive intactness, as indicated by a BIMS score of 15, the resident was not allowed to smoke outside the hours of 7:00AM to 7:00PM, as enforced by facility staff. Interviews with various staff members, including the Smoking Aide, Receptionist, CNA/Receptionist, Director of Nursing, and Administrator, confirmed that the facility restricted smoking to the hours of 7:00AM to 7:00PM. This restriction was due to the Smoking Aide's working hours, and staff were instructed to prevent residents from smoking outside these times. The Administrator acknowledged that security staff should not have been stopping residents from smoking outside the designated hours, indicating a lack of adherence to the resident's rights as outlined in the facility's policies.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status documented in the medical record was consistent with the resident's wishes. Specifically, for one resident, there was a discrepancy between the code status indicated in the resident's chart/medical record and the electronic medical record (EMR). The resident's chart/medical record indicated a Full Code status, meaning medical interventions would be performed in the event of no pulse or breath, while the EMR and physician's orders indicated a Do Not Resuscitate (DNR) status, instructing healthcare providers not to perform cardiopulmonary resuscitation (CPR). Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) would rely on the resident's chart/medical record to verify code status during an emergency, which showed a Full Code status. However, the Director of Nursing (DON) confirmed the discrepancy, acknowledging that the EMR and physician's orders indicated a DNR status. This inconsistency in documentation could lead to confusion and inappropriate medical interventions, highlighting a failure in maintaining accurate and consistent records of the resident's code status according to their wishes.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) forms to residents prior to the termination of Medicare Part A services. This deficiency was identified for three residents who were sampled for termination of Medicare Part A services. For each resident, there was no documented evidence that the NOMNC Form CMS-10123 was given, explained, or signed by the residents or their responsible parties before the discontinuation of services. The facility was unable to present any documentation to confirm that these forms were properly handled. Resident #62, Resident #68, and Resident #234 were all affected by this deficiency. Resident #62's last day of Medicare Part A services was on 07/29/2024, Resident #68's on 08/07/2024, and Resident #234's on 12/09/2024. In each case, the facility's administrator confirmed the lack of documentation and explanation of the NOMNC forms. Additionally, the SNFABN forms were signed inadvertently without proper explanation to the residents or their responsible parties. Resident #68 was noted to have severe cognitive impairment, which further emphasizes the importance of ensuring that responsible parties are adequately informed and involved in the process.
Inaccurate Dental Assessments for Two Residents
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments for two residents regarding their dental status. Resident #61 was admitted with moderate cognitive impairment, as indicated by a BIMS score of 11. However, the admission Minimum Data Set (MDS) assessment inaccurately reported no oral and dental issues, despite observations and the resident's own admission of missing several teeth. The facility administrator could not provide an explanation for this discrepancy. Similarly, Resident #75, who had an intact cognitive status with a BIMS score of 15, was also inaccurately assessed as having no dental issues upon admission. Observations and interviews with the resident and two LPNs confirmed that the resident was missing several teeth at the time of admission. Again, the facility administrator was unable to explain the inaccuracy in the MDS assessment for this resident's dental status.
Failure to Maintain Level II PASARR Documentation
Penalty
Summary
The facility failed to provide documentation of a resident's Level II Pre-Admission Screening and Resident Review (PASARR) for one of the sampled residents. The medical record of the resident, who was admitted with diagnoses of Schizophrenia, Bipolar Disorder, and Unspecified Dementia, did not contain the necessary Level II PASARR documentation. This documentation was supposed to be completed by the Office of Behavioral Health and maintained in the resident's medical record. During interviews, both the social services staff and the administrator acknowledged the absence of the required documentation in the resident's medical record, confirming that it should have been maintained.
Failure to Supervise Unsafe Smoker
Penalty
Summary
The facility failed to ensure safe smoking interventions for a resident identified as an unsafe smoker. Resident #45, who was admitted with diagnoses including vascular dementia, tremors, and epilepsy, was listed on the facility's Unsafe Smoker List. The resident had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 03. The care plan for Resident #45 required supervision while smoking and specified that smoking supplies should be obtained from a designated smoke aide. During an observation, the smoking aide was seated 10 to 15 feet away from Resident #45, with the resident's back turned towards the aide. Resident #45 was given a cigarette by another resident and had it lit by yet another resident, while facing away from the smoking aide. Interviews with the smoking aide and a certified nursing assistant confirmed that Resident #45 was an unsafe smoker who required direct visualization while smoking. The facility administrator also indicated that unsafe smokers should not receive smoking materials from other residents, highlighting a failure in supervision and adherence to the care plan for Resident #45.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication was not ordered on an as-needed basis for more than 14 days. Specifically, Resident #55 had a physician's order dated 09/28/2024 for Lorazepam, a psychotropic medication used to treat anxiety, to be administered 0.5 mg every eight hours as needed. There was no documented evidence that the physician provided a clinical rationale for the continuation of this order or specified a duration for the medication. During an interview on 01/30/2025, the Director of Nursing acknowledged that the facility should have clarified the duration and the physician's rationale for continuing the medication order for Resident #55.
Failure to Notify Physician of Incomplete Laboratory Test
Penalty
Summary
The facility failed to notify a physician when laboratory tests were not completed as ordered for a resident. A pharmaceutical consultant recommended a Complete Blood Count (CBC) for the resident every six months, and a physician's order was placed to begin this schedule. However, there was no documented evidence that the CBC was completed in January 2025 as ordered. The laboratory results indicated that the CBC was not completed due to the laboratory's inability to obtain a blood specimen, yet there was no documentation of the physician being informed of this issue. During an interview, the Director of Nursing acknowledged that the physician should have been notified if the CBC was not completed, and there should have been documentation of this notification. The lack of communication and documentation regarding the incomplete laboratory test represents a deficiency in the facility's process for ensuring that ordered laboratory services are provided and that physicians are promptly informed of any issues in obtaining test results.
Failure to Provide Dental Services to Residents
Penalty
Summary
The facility failed to provide necessary dental services to two residents, resulting in a deficiency. Resident #61 was observed to be missing several upper and lower teeth and expressed a desire to see a dentist and obtain dentures. Despite being admitted to the facility, there was no documented evidence that Resident #61 had been evaluated for dental services. The facility's dental treatment schedule did not include Resident #61, and interviews with social services and the administrator confirmed the lack of evaluation without providing a reason. Similarly, Resident #75 was also missing several teeth and had not seen a dentist since admission, despite expressing a desire for dental services and dentures. Like Resident #61, there was no documented evidence of a dental evaluation for Resident #75, and the resident was not listed on the facility's dental treatment schedule. Interviews with social services and the administrator again confirmed the absence of dental evaluation, with no explanation provided for this oversight.
Facility Dumpster Not Maintained Sanitarily
Penalty
Summary
The facility failed to maintain its dumpster in a sanitary manner, as observed on two separate occasions. On January 28, 2025, at 10:35 AM and again at 12:40 PM, the dumpster was found to be missing a lid and was open to the air, with loose trash scattered on the ground around it. Interviews with the Dietary Manager and the Administrator confirmed awareness of the missing lid and acknowledged that the trash should have been contained. Both staff members admitted that the dumpster and its surrounding area were not maintained in a sanitary manner, as they should have been.
Lack of Involvement in Facility Assessment
Penalty
Summary
The facility failed to ensure active involvement from direct care staff, residents, and residents' representatives in the development of its facility-wide assessment. The assessment, dated on an unspecified date, lacked documented evidence of participation from a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), a resident, and/or a resident representative. This deficiency was confirmed during an interview with the facility's administrator on January 30, 2025, who acknowledged the absence of such documentation.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents, despite having signed consents for the vaccinations. Resident #43 signed a consent form to receive the pneumococcal vaccine on April 5, 2024, but there was no documented evidence that the vaccine was administered or that it was medically contraindicated. Similarly, Resident #81's responsible party signed a consent for the pneumococcal vaccine on October 11, 2024, yet there was no documentation to confirm the vaccine was given or medically contraindicated. Interviews with the facility's administrator confirmed the lack of documentation for both residents, indicating a failure in the facility's vaccination administration process.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure the administration of the COVID-19 vaccine to a resident, despite having obtained consent from the resident's responsible party. Specifically, the consent for the COVID-19 vaccine for Resident #81 was signed on 10/11/2024, but there was no documented evidence that the vaccine was administered or that it was medically contraindicated. During an interview on 01/30/2025, the administrator confirmed the lack of documentation regarding the administration or contraindication of the vaccine for Resident #81.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and review individualized fall prevention interventions for three residents who experienced multiple falls. Resident #1, who had severe cognitive impairment and used a manual wheelchair, experienced several falls, including an unwitnessed fall with injury. Despite the facility's policy requiring new interventions after each fall, there was no documented evidence that these interventions were implemented or reviewed for effectiveness. Interviews with the Director of Nursing and staff confirmed the lack of documentation and updates to the resident's care plan. Resident #2, also with severe cognitive impairment and a history of falls, experienced multiple falls, including one with injury. The facility's records showed no evidence of individualized post-fall interventions being implemented or reviewed for effectiveness. Staff interviews revealed that updates on fall interventions were not communicated to those primarily responsible for the resident's care. Resident #3, who was cognitively intact but had vision and hearing impairments, experienced several falls, including one with injury. The care plan was not updated with new interventions or increased supervision after these incidents. Interviews with nursing staff and CNAs confirmed the absence of documented evidence for new interventions and a lack of communication regarding updates to the resident's fall prevention strategies.
Failure to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, as observed during a survey. For one resident, a brown smear was noted on the wall above the trash can in their room, which was confirmed by the administrator. This indicates a failure to adhere to the facility's Bathroom Policy, which requires daily cleaning of walls, wash basins, commodes, and floors. For another resident, multiple observations revealed significant unsanitary conditions in their room and bathroom. The isolation cart outside the room was visibly dirty, and the room itself had a brown substance on the wall, dirt on the bedside table and floor, and a chicken bone under the table. Additionally, nutrition shakes were found on the floor next to unlabeled and uncovered urinals, and the bedside table was cluttered with an unopened breakfast plate, a cup with ointment remnants, and a water pitcher with a brownish film. The bathroom had a brown substance smeared on the toilet seat and base, and toothpaste was spilled on the counter. Interviews with the housekeeper, DON, and facilities manager confirmed the unsanitary conditions, and the resident expressed dissatisfaction with the cleanliness of their room and bathroom.
Incomplete Investigation of Resident's Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect concerning an injury of unknown origin for a resident. The resident was found to have a dislocated left hip, which was discovered in the morning after being put to bed the previous evening with an abductor cushion in place. The facility's investigation was incomplete, as it did not include statements from all relevant staff members who were present during the time of the incident. The investigation documentation revealed that only two statements from CNA staff were obtained, and there was no evidence of statements from other staff members who had observed the resident's condition. Notably, the LPNs who assisted with the resident's care during the night shift did not document their observations of the resident's swollen hip, nor were they asked to provide statements about their knowledge of the incident. Additionally, a CNA who noticed the resident's hip condition during breakfast was not questioned or asked to provide a statement. Interviews with the Director of Nursing and the Administrator confirmed that they did not obtain statements from all nursing staff involved, believing it was only necessary to get statements from direct care staff. This oversight resulted in a lack of comprehensive documentation and understanding of the events leading to the resident's injury, as required by the facility's abuse prevention policy.
Failure to Revise Care Plan After Resident Falls and ADL Decline
Penalty
Summary
The facility failed to revise a resident's care plan to address significant changes in their condition, specifically a decline in activities of daily living (ADLs) and incidents of falls. The resident, who had severely impaired cognition with a BIMS score of 3, was dependent on staff for transfers and mobility. The resident experienced a witnessed fall from a wheelchair resulting in a left hip fracture and an unwitnessed fall from bed with no apparent injury. Despite these incidents, the care plan was not updated to reflect the falls or the decline in bed mobility and transfers due to the hip fracture. This deficiency was confirmed during an interview with the facility administrator.
CNA Found Asleep on Duty
Penalty
Summary
The facility failed to ensure that staff was available at all times to provide care and services to meet the residents' needs, as evidenced by a Certified Nursing Assistant (CNA) being observed asleep while on duty. The CNA, identified as S6CNA, was assigned to provide care to seven residents during a day shift from 7:00 a.m. to 7:00 p.m. on floor x. On the day of the observation, the CNA was found slouched over in a chair with eyes closed in the hallway, indicating he was asleep. This incident was observed by administrative staff and later confirmed by the Director of Nursing (DON), who woke the CNA and addressed the issue. The CNA had previously signed the facility's Employee Code of Conduct, which explicitly stated that sleeping while on duty was a violation warranting immediate termination. Despite this, the CNA was found asleep during his shift, which was confirmed through interviews with both the CNA and the facility's Administrator. The Administrator confirmed that the CNA should not have been asleep while on duty, highlighting a failure to adhere to the facility's staffing requirements and code of conduct.
Uncertified Staff Working Independently as Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were trained and competent, and that those who had worked less than four months were enrolled in appropriate training. This deficiency was identified for eight staff members, including direct service workers and a front desk receptionist, who were working independently as nurse aides without meeting the minimum state-approved competency and training requirements. The Immediate Jeopardy occurred when these staff members were allowed to work independently with residents, providing direct care without the necessary certification or supervision. The survey team observed multiple instances where uncertified staff were working independently throughout the facility. For example, S4DSW was seen working on various floors and confirmed in an interview that she had not taken the state-approved certification test despite completing a CNA course. Similar findings were noted for S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR, all of whom were working independently as nurse aides without having met the required competency and training standards. Interviews with these staff members revealed that they were not currently enrolled in or scheduled for any CNA certification courses. The facility's policy and procedure required sufficient qualified nursing staff to provide safe and effective care to residents. However, the review of personnel files, time cards, and CNA Break and Lunch Schedule Sheets indicated that uncertified staff were assigned to work independently, providing direct care to residents. Interviews with the Human Resources Manager, Director of Nursing, and Administrator confirmed that they were unaware of the certification status of these staff members, leading to a situation where all 79 residents in the facility were at risk of harm due to the actions of uncertified staff providing direct care without supervision.
Failure to Ensure Staff Competency and Training Requirements
Penalty
Summary
The facility failed to ensure that staff working as nurse aides met the minimum state-approved competency and training requirements. This deficiency was identified for 8 out of 13 personnel files reviewed. The lack of administrative oversight resulted in an Immediate Jeopardy situation when the facility allowed unqualified staff to work independently as nurse aides, providing direct care to residents without the necessary certification or training. This situation persisted over several months, as evidenced by time cards and schedule sheets reviewed by the survey team. The Immediate Jeopardy was identified on 02/09/2024, when staff members S4DSW, S11DSW, and S12DSW were observed working independently without the required qualifications. Further review of the CNA Break and Lunch Schedule Sheets revealed that additional staff members, including S5DSW, S6DSW, S7DSW, S8DSW, and S15FDR, were also assigned to work as nurse aides without meeting the state-approved competency and training requirements. Interviews with the Human Resources Manager, Director of Nursing, and Administrator confirmed that these staff members were not certified and were improperly assigned to provide direct care to residents. The Administrator acknowledged awareness of the situation and confirmed that all 79 residents were at risk of serious injury or harm due to the actions of the uncertified staff. The Human Resources Manager admitted to being unaware that the facility could not hire DSWs to provide direct care, and the Director of Nursing assumed that only certified staff were hired. The Chief Compliance Officer also stated that he was unaware of the situation and emphasized that uncertified staff should not have been allowed to work as nurse aides. The Immediate Jeopardy was removed on 04/04/2024 after the facility implemented an acceptable Plan of Removal.
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.
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