Citations in Louisiana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Louisiana.
Statistics for Louisiana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Louisiana
A resident who required staff assistance for all ADLs had multiple instances where care provided or refusals were not documented in the electronic medical record. Staff interviews revealed that system limitations prevented CNAs from recording care when it was provided by someone other than the assigned staff or outside of scheduled bath days, resulting in incomplete records. Supervisory staff confirmed the missing documentation and acknowledged no alternative records were available.
A resident receiving tube feeding did not have accurate documentation of enteral feeding administration and gastric residual volume (GRV) checks by an LPN. The LPN recorded that feedings were restarted when they were not, and failed to document subsequent GRV checks and the actual time feedings were resumed, contrary to facility policy and professional standards.
A resident with a PEG tube did not have Enhanced Barrier Precaution (EBP) signage posted as required, and staff—including an LPN and two aides—failed to wear gowns during high-contact care activities such as PEG tube care and transfers. Staff interviews revealed they were unaware of the resident's EBP status and acknowledged that proper PPE should have been used.
Two residents in semiprivate rooms did not have ceiling-suspended privacy curtains around their beds, as observed during multiple surveyor visits. Staff and the DON confirmed the absence of required privacy measures for these residents.
Three residents with significant cognitive and physical impairments experienced multiple falls, but their care plans were not updated to include new fall prevention interventions after each incident. Staff confirmed that care plans remained unchanged despite documented falls, as shown in incident reports and nurse's notes.
A resident with severe cognitive impairment and a history of falls was not provided with non-skid socks as required by their care plan. Staff and the DON confirmed the omission, and the resident's representative also noted the absence of non-skid socks, despite this being a documented fall prevention intervention.
A resident with multiple chronic conditions did not receive their prescribed PRN Hydrocodone-Acetaminophen due to the medication not being available. An LPN borrowed the same medication from another resident and administered it, contrary to facility policy and professional standards. The incident was observed by staff and family, and confirmed by the DON and RN Supervisor.
A resident with chronic pain and opioid dependence was left without prescribed Hydrocodone-Acetaminophen due to failures in medication ordering and communication among nursing staff. In response, an LPN administered Tylenol without a physician order and later borrowed pain medication from another resident, violating medication protocols. The resident's family raised concerns about pain management, and the resident was transferred to the hospital for pain control.
A resident was discharged from the facility while their appeal of the discharge was still pending, despite facility policy and federal requirements stating that residents must be allowed to remain until a decision on the appeal is made.
Two residents with diagnoses requiring fluid management did not have daily weights obtained and documented as ordered by their physicians. Over several months, one resident missed 33 daily weights, and another had no weights recorded on two consecutive weekends. Staff interviews revealed unclear responsibility for weekend weight checks and a lack of daily verification by nursing leadership, resulting in unaddressed gaps in monitoring.
Incomplete Documentation of Activities of Daily Living for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required staff assistance with all activities of daily living (ADLs), including toileting, showering, and bathing. The resident was cognitively intact and had a care plan indicating dependence on staff for hygiene and grooming, with specific instructions for staff to assist as needed and to document both care provided and refusals. However, review of the resident's documentation for October and November revealed multiple dates with missing entries for morning and evening care, as well as inconsistencies in recording refusals of baths or showers. Interviews with certified nursing assistants (CNAs) and supervisory staff revealed that the resident frequently refused care from certain staff members but would accept care from others. When care was provided by a CNA not assigned to the resident, that CNA was unable to document the care in the electronic medical record due to system limitations. Additionally, the electronic system only allowed documentation on assigned bath days and for the day shift, preventing accurate recording of care provided at other times or by other staff. As a result, care that was provided or refused was often not documented, leaving gaps in the resident's medical record. Supervisory staff, including the Director of Nursing and Assistant Director of Nursing, confirmed the missing documentation and acknowledged that the only record of ADL care was the electronic medical record, with no alternative documentation available. The administrator and previous Director of Nursing also confirmed the deficiency and noted that a change in computer software had occurred during the period in question, but there was no evidence that the documentation issues were identified or corrected. No further documentation was available to address the missing records.
Failure to Accurately Document Enteral Feeding and Residual Checks
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral nutrition via a PEG tube. According to the facility's policies and the LPN job description, staff are required to document the date, time, and amount of gastric residual volume (GRV) checks, as well as the administration times of enteral feedings. For the resident in question, physician orders specified a continuous feeding regimen with specific start and stop times. However, documentation inconsistencies were identified: the LPN recorded that the resident's enteral feedings were restarted at a certain time, but subsequent observations and interviews revealed that the feeding pump was off and the tubing was not connected at that time. The LPN later acknowledged that the documentation indicating the feeding had been restarted was inaccurate. Further, when the LPN performed a GRV check and later restarted the resident's enteral feeding, these actions were not documented in the resident's medical record as required. The nurse's notes lacked entries for the actual time the feeding was restarted and for the GRV check, including the date, time, and amount. The DON confirmed that the LPN should have accurately documented all relevant information regarding the resident's enteral feeding and residual checks, in accordance with facility policy and professional standards.
Failure to Post EBP Signage and Ensure PPE Use for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring Enhanced Barrier Precaution (EBP) signage was posted for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, as required by facility policy. Observations on two separate occasions revealed that no EBP signage was present on or around the resident's door or bed, despite physician orders and care plan documentation indicating the need for EBP due to the presence of an indwelling medical device. Staff interviews confirmed the absence of signage and acknowledged that it should have been posted to alert staff and visitors. Additionally, staff did not consistently wear the required personal protective equipment (PPE), specifically gowns, during high-contact care activities for the resident on EBP. Observations showed that an LPN performed PEG tube care and two staff members conducted a transfer using a Hoyer lift without wearing gowns, contrary to facility policy and the resident's care plan. Interviews with the involved staff revealed a lack of awareness that the resident was on EBP and an acknowledgment that gowns should have been worn during these activities. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP signage and appropriate PPE use were required but not followed in these instances.
Lack of Privacy Curtains in Semiprivate Rooms
Penalty
Summary
The facility failed to provide required privacy measures for residents in semiprivate rooms, as evidenced by the absence of ceiling-suspended privacy curtains around the beds of two residents. Observations conducted on multiple occasions revealed that both residents, who were sharing rooms with roommates, did not have the necessary privacy curtains installed to ensure visual privacy. Staff interviews confirmed that these residents were in semiprivate rooms and acknowledged the lack of privacy curtains. The Director of Nursing also confirmed that residents in such rooms should have ceiling-suspended privacy curtains to maintain privacy.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for three residents following multiple documented falls. Each resident experienced one or more falls, as evidenced by incident reports and nurse's notes, but their care plans were not updated to reflect new or revised fall prevention interventions after these incidents. This lack of timely care plan revision was confirmed through record review and staff interviews. One resident with severe cognitive impairment and diagnoses including repeated falls, a progressive neurological condition, and Parkinson's Disease experienced three separate falls. Despite these incidents, the resident's care plan was not revised to address the specific circumstances or to implement new interventions after each fall. Staff interviews confirmed that the care plan remained unchanged prior to the survey. Another resident with Alzheimer's Disease and a history of falls, as well as a third resident with multiple fractures and neuropathy, also experienced falls that were not followed by updates to their respective care plans. In each case, staff acknowledged during interviews that the care plans should have been revised to reflect the falls and to include appropriate interventions, but this was not done prior to the survey team's review.
Failure to Implement Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a fall prevention intervention as identified in the care plan for a resident with a history of repeated falls, progressive neurological condition, and Parkinson's Disease with dyskinesia. The resident, who had severe cognitive impairment as indicated by a BIMS score of 3, was care planned to wear non-skid socks as a fall prevention measure following a previous fall incident. However, during observations, the resident was found wearing regular socks without non-skid bottoms. Multiple staff members, including nursing staff and the Director of Nursing, confirmed that the resident was a fall risk and that the care plan required the use of non-skid socks. Staff observed and acknowledged that the resident was not wearing the prescribed non-skid socks at the time of the survey. The resident's representative also reported that the resident does not wear non-skid socks, despite the documented intervention on the care plan.
Failure to Administer Ordered Controlled Medication and Improper Borrowing of Medication
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that controlled medications ordered for a resident were administered as prescribed. Specifically, the resident had a physician's order for Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for pain. However, due to the facility not having the resident's pain medication available, an LPN borrowed the same medication from another resident and administered it to the resident in need. This action was acknowledged by the LPN, who stated she knew it was not appropriate, and was confirmed by the Director of Nursing and RN Supervisor. The resident involved had multiple diagnoses, including COPD, Type II Diabetes Mellitus with neuropathy, severe dementia with agitation, opioid dependence, and anxiety disorder. The resident was cognitively intact and required some assistance with activities of daily living. The lack of medication availability was noted by staff over several days, and the improper administration of another resident's medication was observed and reported by staff and family members. The facility's policy required strict adherence to medication administration standards, including verifying the right resident and medication, which was not followed in this instance.
Failure to Ensure Timely Acquisition and Proper Administration of Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely acquisition and dispensing of a controlled medication, Hydrocodone-Acetaminophen, for a resident with multiple diagnoses including chronic pain conditions and opioid dependence. The resident was admitted with a prescription for Hydrocodone-Acetaminophen to be given as needed for pain, but the medication supply was depleted on 12/03/2025. The process for reordering the medication was not properly followed, as the empty medication card was left on the Assistant Director of Nursing's desk without direct communication, and the responsible staff did not ensure the order was placed or received. During the period when the resident was without his prescribed pain medication, staff attempted to manage his pain by administering Tylenol, for which there was no physician order, and later by borrowing Hydrocodone-Acetaminophen from another resident, which is a violation of medication administration protocols. Multiple staff interviews confirmed that the breakdown in communication and lack of clear responsibility for medication ordering led to the resident being without his PRN pain medication for several days. The resident's family became aware of the situation and expressed concern about neglect related to pain management. The resident ultimately required transfer to the hospital for pain management at the family's request. Documentation and interviews revealed that the facility's procedures for controlled substance administration and accountability were not followed, resulting in the resident not having access to his prescribed pain medication when needed. The failure to ensure the availability of the medication and the inappropriate borrowing of another resident's medication were directly observed and confirmed by staff and administrative personnel.
Resident Discharged While Appeal Pending
Penalty
Summary
The facility failed to comply with its own Transfer and Discharge policy and federal requirements by discharging a resident while an appeal of the discharge was still pending. According to the facility's policy and the discharge notice provided to the resident, residents have the right to remain in the facility until a decision on their appeal is rendered. In this case, a resident was issued a 30-day discharge notice and subsequently filed an appeal within the allowed timeframe. Despite being notified of the pending appeal, the facility proceeded to discharge the resident on the effective date listed in the notice, prior to the resolution of the appeal. This action was confirmed through record review and interview with the facility administrator.
Failure to Obtain and Document Daily Weights for Residents with Fluid Management Needs
Penalty
Summary
The facility failed to follow physician orders to obtain and document daily weights for two residents with diagnoses including congestive heart failure and fluid overload. For one resident, there were 33 instances over several months where daily weights were not recorded, despite clear physician orders and care plan interventions specifying the need for daily monitoring. The resident's responsible party reported that the facility provided various excuses for not obtaining weights, such as malfunctioning equipment or inability to locate the scale, and that the facility did not implement the physician's orders in a timely manner. There was no documentation indicating that the resident refused to be weighed on the missed days. Staff interviews revealed that the CNA/Weight Tech was responsible for obtaining weights Monday through Friday, while floor CNAs were expected to obtain weights on weekends. However, the process for ensuring weights were obtained on weekends was not effectively managed, and nurses were identified as ultimately responsible for ensuring compliance with orders. The Assistant Director of Nursing (ADON) generated weekly weight reports but did not verify daily compliance by reviewing each resident's chart, resulting in unawareness of the missed weights. The Director of Nursing (DON) and ADON both confirmed that staff should have identified and addressed the missed weights, and that the resident could have been weighed even if in a chair using a Hoyer lift. A second resident with orders for daily weights also had undocumented weights on two consecutive weekends. The ADON confirmed that daily weights were ordered and acknowledged that staff did not identify the missed documentation. Both residents had medical conditions requiring close monitoring of fluid status, and the failure to obtain and document daily weights as ordered was confirmed through record review and staff interviews.
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