Many Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Many, Louisiana.
- Location
- 120 Natchitoches Hwy 6 East, Many, Louisiana 71449
- CMS Provider Number
- 195310
- Inspections on file
- 29
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Many Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Pureed Meal Recipes Not Followed: A dietary staff member prepared pureed turkey, cornbread dressing, and green bean casserole without measuring portions or using the pureed recipe menu, despite the menu specifying exact serving sizes for 13 residents on pureed diets. The RD confirmed staff were supposed to use the recipe menu, and the Admin acknowledged the cooks did not use the recipe menus for the lunch pureed meals.
Unsafe food service and improper dish storage. The facility failed to monitor steam table food temperatures for multiple meals and days, despite policy requiring temperature checks throughout the meal. In addition, a dirty, dusty electric fan was observed blowing on clean dishes in a drying rack, and the DM confirmed the fan was being used to dry the dishes and should not have been dirty.
Failure to Notify Ombudsman of Resident Discharges: The facility failed to send written transfer/discharge notices to the Ombudsman for two residents reviewed. One resident was discharged home with HH skilled PT/OT after fractures of the hand, ribs, and thumb, and another resident with femur and humerus fractures plus disorientation was discharged after an ER transfer order for chest pain. The BOM stated she was responsible for reporting the transfer logs but was unaware planned or actual discharges had to be reported.
A resident with diagnoses including unspecified dementia, major depressive disorder, psychotic disorder with delusions, and age-related cognitive decline had a quarterly MDS showing severe cognitive impairment and need for partial/moderate assistance with ADLs. The resident was coded for Non-Alzheimer’s Dementia, but the most recent care plan had no documented evidence of a dementia-related care plan, which an LPN/MDS confirmed should have been in place.
Failure to Assess Dialysis Catheter: A resident with ESRD, CKD, and severe cognitive impairment had a dialysis catheter in the left chest wall with a dressing in place, but the record contained no documentation that the CVC was monitored or assessed. The care plan called for monitoring the dialysis access and reporting signs of infection, and an LPN stated the resident had a port for hemodialysis, while the DON confirmed the catheter was not placed on the MAR for monitoring or assessment.
Oxygen Not Administered as Ordered: A resident with chronic respiratory failure and severe cognitive impairment was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the resident receiving 1 L/min on multiple occasions. An LPN stated the resident should not have been on 1 L of oxygen, and a Unit Manager confirmed the resident was receiving less than the ordered amount.
Infection control measures were not followed when an LPN used an unclean wrist blood pressure device between uses with multiple residents during medication administration. The facility’s policy stated that the IPCP is maintained to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The LPN acknowledged the equipment was not cleaned between residents, and the DON later confirmed this.
A resident's medications were left unattended at the bedside, contrary to the facility's policy requiring safe and timely administration. The resident, with intact cognition, fell asleep before taking the medications. An LPN admitted to not ensuring the medications were taken, and the DON confirmed this was against nursing standards.
The facility did not complete annual performance reviews for four CNAs within the required 12-month period. Personnel records for these CNAs lacked evidence of a completed and signed review by the department head. Interviews with the administrator and corporate HR confirmed the requirement for annual evaluations, which were not conducted for the CNAs involved.
The facility did not post daily nurse staffing information, including the resident census and hours worked by RNs, LPNs, and CNAs. Observations showed outdated staffing data, and interviews revealed uncertainty about responsibility for updates over the weekend. The administrator confirmed the information should have been posted daily but was not.
The facility failed to meet the nutritional needs of residents on pureed diets by not following recipes and portion sizes. An employee prepared meals without using the recipe binder, resulting in incorrect consistency and portion sizes. During meal service, incorrect serving utensils were used, leading to improper portion sizes. The Dietary Manager confirmed these deficiencies.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with undated and improperly stored food items, lack of temperature monitoring, and inadequate hygiene practices among staff. Observations revealed dirty equipment, uncovered food, and incomplete documentation of sanitizing procedures, leading to unsanitary conditions and a hair found in food served to residents.
A facility failed to notify the Ombudsman in writing of a resident's discharge, as required by policy. The resident was discharged to a behavioral hospital, but the Business Office Manager did not send the necessary notification. Interviews with staff confirmed the oversight, and the Corporate RN acknowledged the failure to comply with notification requirements.
A facility failed to refer a resident with a new diagnosis of Schizoaffective Disorder for a Level II PASARR evaluation. The Social Services Director initially believed the resident did not meet the criteria, but later confirmed the need for the evaluation after reviewing the resident's diagnoses. This oversight resulted in a deficiency.
A facility failed to implement a comprehensive care plan for a resident on NPO status due to severe cognitive impairment and medical conditions. Despite orders for tube feeding, a water pitcher was found in the resident's room, and a CNA admitted to giving the resident sips of water. Interviews revealed a lack of staff understanding and communication regarding the resident's NPO status.
A facility failed to document a discharge summary for a resident with a complex medical history, including a femur fracture and osteoarthritis, upon their discharge. Although the resident was discharged in stable condition and notifications were made to relevant parties, the absence of a discharge summary was confirmed by the DON and a Corporate RN, violating the facility's policy.
A facility failed to implement Enhanced Barrier Precautions for a resident with complex medical needs, as PPE was not available despite policy requirements. An LPN did not wear a gown during medication administration via PEG tube, confirmed as necessary by the DON, indicating a lapse in infection control practices.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggression in a common area. Despite the aggressor's care plan noting potential for physical aggression, the incident occurred, resulting in a bruise to the victim's ear. Staff intervened to separate the residents.
The facility failed to report resident-to-resident sexual abuse within the required timeframe. An LPN witnessed two incidents over a weekend but did not file an incident report immediately. The DON and Administrator were informed the following Monday, and a SIMS report was filed, confirming the delay in reporting.
A resident with a history of falls and cognitive impairment did not have a fall mat at their bedside, as required by their care plan. Despite being at high risk for falls and having previously sustained a hip fracture, the necessary safety intervention was not in place. The absence of the fall mat was confirmed by the DON during an observation.
A resident's wheelchair was improperly secured with only three of the four required anchors in a transport van, leading to the wheelchair tipping over and the resident sustaining a head injury. The incident occurred due to incomplete weekly safety inspections and untrained staff securing the wheelchair.
A facility failed to ensure a CNA was competent in securing a resident's wheelchair in a van, leading to an accident where the resident sustained a head injury. The CNA used only three of the required four anchors, one of which was a broken makeshift strap. The facility's policy on vehicle safety inspections was also not followed.
Pureed Meal Recipes Not Followed
Penalty
Summary
The facility failed to meet the nutritional needs of residents in accordance with established national guidelines by not following the pureed meal menu portion sizes for 13 residents who received pureed meals prepared by the facility kitchen. The facility policy stated that each resident is to be provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, and the pureed lunch menu and pureed recipe menu specified exact serving sizes and preparation steps for each food item. During observation, a dietary staff member prepared pureed turkey by scooping an unmeasured amount into a smaller pan, then into a blender, and added turkey juice using a 6 oz ladle for a total of 5 ladles. The staff member prepared cornbread dressing by scooping an unmeasured amount into a smaller pan, then into a blender, and added turkey juice using a 6 oz ladle for a total of 3 ladles. The green bean casserole was prepared by pouring half of the container, including the juice, into the blender and adding thickener. The pureed recipe binder was observed closed on the shelf, and the staff member confirmed she did not measure food portions and stated, "I just know how much food to prepare." The RD confirmed dietary staff were supposed to use the recipe menu to prepare pureed meals, and the Admin acknowledged the cooks did not use the recipe menus for lunch pureed meals.
Unsafe Food Service and Improper Dish Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions by not ensuring safe food was served on the food line and by not storing clean dishes appropriately. Review of the facility policy titled Food Preparation and Service stated that food and nutrition services employees are to prepare and serve food in a manner that complies with safe food handling practices, and that steam table food temperatures are to be monitored throughout the meal. However, observation of temperature logs on 03/09/2026 showed that temperatures of prepared steam table foods were not completed for breakfast and lunch on 03/03/2026; breakfast, lunch, and dinner on 03/05/2026 through 03/08/2026; and breakfast on 03/09/2026. In interview, the DM confirmed the temperatures were not completed for the listed dates and meals but should have been. During observation with the DM, a dirty, dusty electric fan was seen blowing on clean dishes placed in a drying rack next to the drying station, and the DM stated the fan was used to dry the dishes and confirmed it was dirty and dusty but should not have been.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfer/discharge for 2 of 2 residents reviewed for transfer/discharge. Review of the facility policy titled, Transfer or Discharge Notices, stated that residents or resident representatives are to be notified in writing of an impending transfer or discharge and that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. The facility's Louisiana Ombudsman Program/Emergency Transfer Log for 01/01/2026-03/11/2026 did not include Resident #2's planned discharge home, and S10 BOM stated she was responsible for reporting the transfer logs to the LA Ombudsman Program but was unaware that planned discharges or any discharges had to be reported. S10 BOM confirmed Resident #2's planned discharge home was not reported. Resident #2 was admitted on 02/12/2026 and discharged on 03/04/2026. The resident had diagnoses including displaced fracture of the shaft of the fourth metacarpal bone of the right hand, multiple right rib fractures, and displaced fracture of the distal phalanx of the right thumb. Physician orders dated 03/02/2026 directed discharge home with LA Homecare Home Health skilled nursing therapy services on 03/04/2026, and the discharge summary stated the resident was discharged home with LA Home Care with skilled PT/OT. Resident #81 was admitted on 01/30/2026 and discharged on 02/07/2026 with diagnoses including displaced mid-cervical fracture of the left femur, 2-part displaced fracture of the surgical neck of the left humerus, and disorientation, unspecified. The report also noted a physician order to send the resident to the emergency room for evaluation/treatment due to chest pain on 02/07/2026.
Missing Dementia Care Plan
Penalty
Summary
The facility failed to ensure that a person-centered plan of care was developed for Resident #6 to reflect a diagnosis of dementia. Resident #6 was admitted with diagnoses including unspecified dementia, major depressive disorder, psychotic disorder with delusions due to a known physiological condition, and age-related cognitive decline. The resident’s quarterly MDS with an ARD of 12/29/2025 showed a BIMS score of 99, indicating severe impaired cognition, and documented that the resident required partial/moderate assistance with oral hygiene, bathing, and toilet use. The MDS also coded the resident for a diagnosis of Non-Alzheimer’s Dementia. Review of the resident’s most recent care plan showed no documented evidence of a care plan related to the dementia diagnosis. During interview on 03/11/2026 at 11:43 a.m., an LPN/MDS confirmed that Resident #6 did not have a care plan related to the dementia diagnosis, but should have.
Failure to Assess Dialysis Catheter
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not assessing a Central Venous Catheter for one resident. The resident had diagnoses including End Stage Renal Disease, Hypertensive Chronic Kidney Disease, Protein-Calorie Malnutrition, Human Immunodeficiency Disease, and Acute on Chronic Diastolic Heart Failure, and the Quarterly MDS showed severe cognitive impairment with a BIMS score of 7. The care plan directed staff to monitor the dialysis catheter to the left chest wall as ordered and to monitor, document, and report signs or symptoms of infection such as redness, swelling, warmth, or drainage. The resident’s physician orders included dialysis three days a week at a dialysis center. During observation, the resident was seen sitting in a wheelchair outside on the patio with a dressing on the left chest wall and was unable to state whether staff were monitoring the dialysis catheter. An LPN stated the resident had a port to the left chest wall for hemodialysis and that this was documented on the MAR. However, review of the March 2026 medical record showed no documentation that the Central Venous Catheter to the left chest was monitored or assessed. The DON confirmed the resident previously had an Internal Jugular Catheter that was discontinued and that the Central Venous Catheter in the left chest wall was not placed on the MAR for monitoring or assessment, although it should have been.
Oxygen Not Administered as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided when the facility failed to ensure oxygen was administered as ordered for one resident. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, and functional quadriplegia. The resident’s physician orders directed oxygen at 2 liters per minute via nasal cannula continuously for chronic respiratory failure, and the resident’s MDS indicated severe cognitive impairment and that oxygen therapy was required. Observations showed the resident in bed with oxygen running at 1 liter per minute via nasal cannula instead of the ordered 2 liters per minute. This was observed multiple times, including when the resident was alert to self only and when asleep. An LPN stated the resident should not have been on 1 liter of oxygen, and a Unit Manager later confirmed the resident was ordered continuous oxygen at 2 liters per minute and was currently receiving 1 liter per minute.
Infection Control Failure With Unclean Blood Pressure Equipment
Penalty
Summary
The facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by not ensuring medical equipment was cleaned between uses with multiple residents. Review of the facility’s Infection Prevention and Control Program policy dated 03/03/2026 stated that an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation of medication administration on 03/10/2026 at 9:20 a.m., S9 LPN used an unclean wrist blood pressure medical device between uses with multiple residents. During interview on 03/10/2026 at 10:05 a.m., S9 LPN stated she did not clean the wrist blood pressure medical equipment between uses with multiple residents, but should have. During interview on 03/11/2026 at 3:11 p.m., S2 DON acknowledged that S9 LPN did not clean the wrist blood pressure medical equipment between uses with multiple residents, but should have.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered safely and timely to a resident, identified as Resident #46. The incident involved leaving the resident's morning medications at her bedside, which is against the facility's policy that requires medications to be administered in a safe and timely manner. Resident #46, who has intact cognition as indicated by a BIMS score of 15, was found with a cup of medicine on her bedside table. The resident reported that the nurse had left the medications for her to take, but she fell back asleep before doing so. The medications left at the bedside included several critical prescriptions such as Effexor XR, Eliquis, and Lasix, among others. An LPN confirmed during an interview that she did not ensure the resident had swallowed her medications before leaving the room, acknowledging that she should have done so. The Director of Nursing also confirmed that it is the expectation for nurses to ensure residents swallow their medications and not leave them unattended at the bedside. This oversight in medication administration represents a failure to meet professional standards of practice for the resident involved.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review for four certified nurse aides (CNAs) within the required 12-month period. The personnel records for CNAs S11, S12, S13, and S14 did not contain evidence of a completed and signed annual performance review by the department head. S11 was hired on September 15, 2023, S12 on November 21, 2023, S13 on February 1, 2023, and S14 on April 26, 2023. Interviews with the facility's administrator and corporate HR confirmed that annual performance evaluations are required for all employees, but these were not conducted for the CNAs in question.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the resident census and the total number and actual hours worked by RNs, LPNs, and CNAs responsible for resident care per shift. Observations on January 12, 2025, at 8:40 a.m. and 9:06 a.m. revealed that the staffing information posted was outdated, showing data from January 10, 2025, and missing updates for January 11 and 12, 2025. Interviews with an RN and an LPN indicated uncertainty about who was responsible for updating the staffing information over the weekend. The facility's administrator confirmed that the required staffing information should have been posted daily but was not.
Failure to Follow Pureed Diet Recipes and Portion Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents on pureed diets by not following established recipes and portion sizes. During the preparation of a pureed lunch meal, an employee, S18, was observed adding unmeasured amounts of ingredients to the food processor without following a recipe. S18 was unaware of the recipe binder for pureed food preparation and was instructed to make the food look like baby food. This resulted in the preparation of meals that did not adhere to the required consistency and portion sizes as outlined in the facility's recipe book. Additionally, during the lunch meal service, the pureed diet of beef meatballs was not served with the correct serving utensil. S18 initially used a scoop that measured 1 and 5/8 oz. instead of the required #8 scoop, which measures 1/2 cup or 4 ounces. After being informed by the Dietary Manager, S18 switched to a different scoop, but it still did not meet the required portion size. The Dietary Manager confirmed that the incorrect serving size utensil was used, which did not comply with the posted serving measurements.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions, as evidenced by multiple observations and interviews. During an initial tour of the kitchen, it was noted that several food items in the refrigerator and freezer were not properly dated or sealed. This included undated butter, sausage links, turkey sandwich meat, and various frozen items such as spinach, potatoes, and chicken wings. Additionally, there was a lack of proper labeling and dating for dry foods and opened packages, which is a violation of the facility's policies on food storage and safety. Further observations revealed unsanitary conditions in the kitchen and dining areas. Pan lids were found dirty with food particles, and food items such as hamburger buns and apple juice were left uncovered. The black refrigerator in the dining area lacked a thermometer, and there was no temperature log for the entire month, which is against the facility's policy of monitoring and recording refrigerator temperatures. These lapses in maintaining sanitary conditions and proper documentation were confirmed by the Dietary Manager during interviews. The facility also failed to ensure proper hygiene practices among dietary staff. During a lunch meal service, hair was found in the corndogs, and it was observed that the staff member serving the food wore an inadequate hair covering. Additionally, the Kitchen Aide was unaware of how to document the dishwasher's sanitizer solution concentration, and logs for the dishwasher's sanitizing solution were incomplete. These deficiencies highlight a significant lapse in adhering to professional standards of food service safety and hygiene within the facility.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman in writing of a resident's transfer or discharge, as required by their policy. The policy mandates that residents and their representatives receive written notification of a transfer or discharge at least thirty days in advance, and a copy of this notice must also be sent to the Office of the State Long Term Care Ombudsman. However, a review of Resident #71's electronic health record revealed no documentation that the Ombudsman was notified of the resident's discharge to another facility. Interviews with facility staff confirmed the oversight. The Social Services Director indicated that the Business Office Manager was responsible for sending notifications to the Ombudsman. The Business Office Manager admitted to not submitting the required notification for Resident #71's discharge. Additionally, the Corporate RN confirmed that the facility should have submitted a written notification to the Ombudsman, but failed to do so.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for a Level II PASARR evaluation. The resident, who was admitted with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Vascular Dementia, was later diagnosed with Schizoaffective Disorder. Despite this new diagnosis, there was no evidence that a Level II PASARR evaluation was submitted to the state authority, as required. The Social Services Director, responsible for sending referrals for Level II PASARR evaluations, initially stated that the resident did not meet the criteria for such an evaluation. However, upon reviewing the resident's diagnoses, the Social Services Director acknowledged that the form submitted was incorrect and confirmed that a Level II PASARR evaluation should have been conducted but was not. This oversight led to the deficiency identified in the report.
Failure to Implement NPO Status for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #44, who was on NPO (nothing by mouth) status due to severe cognitive impairment and multiple medical conditions, including dysphagia and hemiplegia. Despite the physician's order and care plan indicating that the resident required tube feeding and should not receive anything by mouth, a water pitcher with a straw was observed on the resident's bedside table. This indicates a lack of adherence to the care plan. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's NPO status. An LPN stated that if the resident requested anything by mouth, she would explain the NPO status, while a CNA admitted to providing the resident with small sips of water, using the water pitcher in the room. The Director of Nursing confirmed that the resident should not have been given water and that the presence of the water pitcher was inappropriate, highlighting a failure in ensuring staff awareness and compliance with the resident's care plan.
Failure to Document Discharge Summary for Resident
Penalty
Summary
The facility failed to document a discharge summary for a resident who was discharged, as required by their policy. The policy, titled 'Transfer or Discharge Documentation and Notice,' mandates that details of a transfer or discharge be documented in the medical record and communicated to the receiving health care provider. However, upon review of the resident's electronic health record and paper medical record, no discharge summary was found. This oversight was confirmed during an interview with the Director of Nursing and a Corporate Registered Nurse. The resident in question had a complex medical history, including a displaced comminuted fracture of the right femur, muscle weakness, osteoarthritis, cognitive communication deficit, age-related osteoporosis, and anxiety disorder. The resident was discharged in stable condition via ambulance, and the necessary notifications were made to the responsible party and physician. Despite these actions, the absence of a documented discharge summary represents a failure to comply with the facility's discharge documentation policy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of Enhanced Barrier Precautions (EBP) for a resident. The facility's policy, dated April 1, 2024, outlined the need for EBP, which includes the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that the necessary personal protective equipment (PPE) was not available at the resident's room, despite the presence of an EBP sign. This oversight was noted on multiple occasions, indicating a lapse in adherence to the facility's infection control policy. The resident involved had a complex medical history, including dysphagia, hemiplegia, dementia, and required tube feeding, making them particularly vulnerable to infections. During a medication administration via PEG tube, an LPN failed to wear a gown, which was confirmed as a requirement by the Director of Nursing. This incident highlights a specific instance where staff practices did not align with the established infection control protocols, potentially increasing the risk of cross-contamination and infection transmission within the facility.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #6, who has severe cognitive impairment, was physically abused by Resident #8, who also has severe cognitive impairment and a history of behavioral problems, including potential physical aggression. On the day of the incident, Resident #8 approached Resident #6 in a common area and physically assaulted her by grabbing her hair and ear. This incident occurred despite Resident #8's care plan noting his potential for aggression. The incident was witnessed by another resident and staff members, who intervened to separate the two residents. Resident #6 sustained a bruise to her left ear as a result of the altercation. The facility's failure to prevent this incident highlights a deficiency in ensuring residents' rights to be free from abuse, as outlined in their Abuse Prohibition Policy.
Failure to Timely Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency within the required timeframe. The incidents involved two residents and occurred over a weekend. The facility's policy mandates that any employee aware of such allegations must report them immediately to the Abuse Coordinator, who is then responsible for reporting to the state agency within two hours if serious bodily injury is involved. However, the Licensed Practical Nurse (LPN) who witnessed the incidents did not file an incident report immediately, as required by the facility's policy. The Director of Nursing (DON) and the Administrator were not informed of the incidents until the following Monday during a morning meeting. Upon learning of the incidents, the DON initiated the Statewide Incident Management System (SIMS) report. The Administrator confirmed that the facility substantiated the allegations but acknowledged that the report was not filed within the required two-hour window after the incidents were discovered. This delay in reporting constitutes a deficiency in the facility's adherence to its abuse reporting policy.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was at high risk for falls. The resident, who had a history of repeated falls and various medical conditions including Alzheimer's disease and schizoaffective disorder, was admitted with a diagnosis of a displaced fracture of the right femur. The resident's care plan included the use of a fall mat at the bedside as an intervention to prevent further falls. However, during an observation, it was noted that there was no fall mat present at the resident's bedside or anywhere in the room. The resident, who had a moderate cognitive impairment with a BIMS score of 11, was able to propel himself in a wheelchair and stated that he did not require assistance for transfers. Despite this, the resident had previously fallen and sustained a hip fracture, requiring surgical intervention. An interview with the Director of Nursing confirmed the absence of the fall mat, which was a required intervention according to the resident's care plan. This oversight indicates a failure to adhere to the prescribed safety measures for the resident, potentially compromising their safety and well-being.
Failure to Properly Secure Wheelchair in Transport Van
Penalty
Summary
The facility failed to ensure residents remained as free of accident hazards as possible, specifically failing to properly secure a resident's wheelchair prior to transporting the resident in one of the facility's vans. This resulted in an immediate jeopardy situation when the resident's wheelchair was anchored with only three of the four required anchors. While the van was in motion, the wheelchair fell backwards, causing the resident to hit the back of her head on the lift, sustaining an abrasion with bleeding noted to the back of her head. The incident occurred because the weekly safety inspections on the transportation van had not been completed by the van driver as directed by the facility's policy. The resident involved had a medical history that included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes mellitus, contracture of the left hand, bipolar disorder, and pain. The resident was cognitively intact and used a manual wheelchair, requiring substantial assistance with transfers. On the day of the incident, the resident was being transported back from a doctor's appointment when the wheelchair, which was improperly secured with only three anchors, tipped over after the van hit a bump. The resident sustained a head injury and complained of a headache following the incident. Interviews with staff revealed that the front right anchor of the wheelchair securement system had been replaced with a manual ratchet strap by the maintenance director, who did not report this change to the administrator. The CNA who secured the wheelchair was not trained to do so and was unaware that the manual ratchet strap was not functioning properly. The transportation driver and CNA both acknowledged that they had been using the van with only three working anchors for some time. The facility's administrator confirmed that the drivers had not been completing the required weekly safety inspections of the van, contributing to the incident.
Failure to Ensure CNA Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was competent in the skills and techniques necessary to assure resident safety during transportation. Specifically, an untrained CNA was allowed to secure a wheelchair-bound resident in a facility van, which led to an accident. The CNA used only three of the required four anchors to secure the resident's wheelchair, and one of the anchors was a makeshift ratchet strap that had been broken for an unspecified period. This resulted in the resident's wheelchair tipping backward when the van hit a bump, causing the resident to sustain an abrasion to the back of the head and experience a headache for several days. The resident was cognitively intact and required substantial assistance with transfers and mobility due to conditions such as cerebral infarction, hemiplegia, and hemiparesis. The incident report and interviews revealed that the CNA had not been trained to secure wheelchairs in the van and was unaware that this task was outside her responsibilities. The CNA who was driving the van admitted to knowing about the broken anchor and had reported it to maintenance, but no action had been taken to repair it. The facility's policy required drivers to complete a weekly vehicle safety inspection, but this had not been done consistently. The administrator confirmed that only drivers were trained to secure wheelchairs and acknowledged that the required safety inspections had not been completed as mandated. The administrator also confirmed that the resident's wheelchair had not been properly secured on the day of the accident.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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